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10925298-DS-6
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Patient recorded as having No Known Allergies to Drugs <ATTENDING> ___ <CHIEF COMPLAINT> right sided abdominal pain <MAJOR SURGICAL OR INVASIVE PROCEDURE> none <HISTORY OF PRESENT ILLNESS> Ms. ___ is ___ yo G1P0 at 18+2 weeks by LMP and first trimester ultrasound who presents for ___ time to E.D. with right sided anterior/lateral pain. Patient was evaluated in ED on ___ ___ for similar concerns. She underwent pelvic ultrasound which revealed mild right hydronephrosis of pregnancy and was otherwise unrevealing. An MRI performed revealed no evidence of appendicitis. A general surgery consult was obtained. A urine analysis was not performed at that time. Patient states she was discharged home with similar right sided pain. The pain improved spontaneously after sleeping but recurred early on ___ morning and she was unable to sleep. Patient denies fevers, dysuria. Normal bowel movements. No bleeding, leakage of fluid, vaginal discharge. No dyspareunia. Denies sick contacts. Denies cough/cold symptoms. No chest pain/shortness of breath. Notes nausea, no vomiting. No cramping/contractions. Has never had a UTI before. <PAST MEDICAL HISTORY> PRENATAL COURSE *)EDC ___ by ___ and first trimester ultrasound *)A+/Ab-/RPRNR/RI/Hep B neg/HIV neg *)Hemoglobin elect. normal *)GC/CT negative *)Urine culture not performed *)Booking BP 100/60 *)Decreased risk ERA OBSTETRIC HISTORY G1 GYNECOLOGIC HISTORY Denies STIs. Sexually active in monogamous relationship with boyfriend, father of baby. PAST MEDICAL HISTORY denies PAST SURGICAL HISTORY denies <SOCIAL HISTORY> ___ <FAMILY HISTORY> non-contributory <PHYSICAL EXAM> VITALS: 99.2 -> 99.8, 109, 110, 123/76, 98/63, 18, 100% room air GENERAL: well, NAD, able to walk to bathroom but appears uncomfortable, tired HEART: tachycardic, RR LUNGS: clear anteriorly and posteriorly, no crackles ABDOMEN: gravid with uterus at umbilicus, soft, tender to palpation in mid right abdomen, right lateral aspect of abdomen and +right CVA tenderness. No fundal tenderness. no suprapubic tenderness. No left sided tenderness/no left CVA tenderness. Negative ___ sign. No RUQ tenderness. SPECULUM: Cervix visualized, closed, long. +Yeast present. No blood noted. GC/CT sent BIMANUAL: Gravid uterus, non-tender. No CMT. No adnexal tenderness. Ovaries not palpated. GU: normal appearing external genitalia, no lesions EXTREMITIES: soft, non-tender bilaterally IMAGING: - ___ Pelvic ultrasound: (final) 1. Normal gallbladder. No evidence of acute cholecystitis. 2. Mild fullness of the right renal collecting system, may be secondary to compression of the right ureter from the gravid uterus. 3. Appendix not visualized. -___ ABDOMINAL MRI: There is an intrauterine gestation with an anterior placenta and long cervix. This examination is not tailored towards assessment of fetal morphology. No significant free fluid is present. Normal ovaries seen. 1. Normal appendix. 2. Mild hydronephrosis of pregnancy. Bedside ultrasound: Active fetal movement, FHR 158. Anterior placenta. Normal fluid. Vertex presentation <PERTINENT RESULTS> ___ WBC-13.5 RBC-3.74 Hgb-10.1 Hct-32.2 MCV-86 Plt-249 ___ Neuts-82.5 ___ Monos-4.5 Eos-0.3 Baso-0.2 ___ Glucose-73 BUN-8 Creat-0.6 Na-135 K-3.9 Cl-101 HCO3-25 ___ URINE Blood-LGE Nitrite-POS Protein-150 Glucose-NEG Ketone-50 Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-MOD ___ URINE ___ WBC->50 Bact-MOD Yeast-NONE Epi-0 Chlamydia trachomatis, Nucleic Acid Probe, with Amplification (Final ___: Negative for Chlamydia trachomatis by PCR. NEISSERIA GONORRHOEAE (GC), NUCLEIC ACID PROBE, WITH AMPLIFICATION (Final ___ for Neisseria Gonorrhoeae by PCR SMEAR FOR BACTERIAL VAGINOSIS (Final ___: POSITIVE: GRAM STAIN CONSISTENT WITH BACTERIAL VAGINOSIS. 2+ ___ per 1000X FIELD): YEAST(S). URINE CULTURE (Final ___: ESCHERICHIA COLI. >100,000 ORGANISMS/ML. SENSITIVITIES: MIC expressed in MCG/ML __________________________________________ ESCHERICHIA COLI AMPICILLIN------------ <=2 S AMPICILLIN/SULBACTAM-- <=2 S CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CEFUROXIME------------ <=1 S CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- <=16 S PIPERACILLIN---------- <=4 S PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S <MEDICATIONS ON ADMISSION> prenatal vitamins <DISCHARGE MEDICATIONS> 1. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 6 days. Disp: *12 Tablet(s)* Refills: *0* 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for Constipation. 3. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 4. Cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q6H (every 6 hours) for 10 days: please take every 6 hours for 10 days, then please take one at bedtime for the remainder of your pregnancy. Disp: *60 Capsule(s)* Refills: *2* 5. Miconazole Nitrate 2 % Cream Sig: One (1) Appl Vaginal HS (at bedtime) for 5 days. Disp: *qs * Refills: *0* <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> pregnancy at 18+4 weeks gestation pyelonephritis <DISCHARGE CONDITION> stable <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> stay well hydrated; continue the antibiotics until course is completed then continue once daily medication for the remainder of the pregnancy. call your doctor with any leaking of fluid, vaginal bleeding, regular or painful contractions, fevers >100.4, or persistent nausea/vomiting.
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Ms. ___ was admitted for pyelonephritis at 18.3 weeks from the Emergency room. . *) Pyelonephritis: Ms. ___ presented with low grade temperature, right quadrant abdominal pain/flank pain and infected urine analysis. She was started on Ceftriaxone IV 1g q 24 hours and hydrated. The patient's urine analysis returned positive for pan-sensitive Ecoli > 100k. She was afebrile x 24 hours before discharge home on Keflex for 10 days with significant clinical improvement in her right lateral/flank pain pain. She was advised to begin once daily prophylactic doses for the remainder of the pregnancy. . Ms. ___ additional workup for right lower quadrant pain included a recent pelvic ultrasound and pelvic MRI which were reassuring. A Gonorrhea/chlamydia swab were negative. The patient was treated for a positive bacterial vaginosis and yeast swab with Flagyl and Monistat respectively. . *) Fetal well being: A bedside ultrasound documented normal fetal movement and normal fluid. A daily fetal heart rate was reassuring.
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10925298-DS-7
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Patient recorded as having No Known Allergies to Drugs <ATTENDING> ___ <CHIEF COMPLAINT> Fever <MAJOR SURGICAL OR INVASIVE PROCEDURE> Lumbar puncture <HISTORY OF PRESENT ILLNESS> ___ yo ___ s/p svd ___ without complications. She presents to ED with fever to 102.3. Pt states that she has not been feeling well for about a week. She reports non-specific body pain and R flank pain. She denies n/v, diarrhea. She reports having some rhinorrhea and a scratchy throat. She has had no difficulty swallowing. She was seen in the office on ___ where she c/o nasal discharge and had a non-focal exam. She states that she felt a little 'lousy', but not too bad. From that point forward, she began to feel worse, developed flank pain and fever. Since her visit in the office, she has also developed a headache. Of note, she had a pan-sensitive pyelonephritis during this pregnancy in ___ treated with IV abx. She had been on supression with keflex until labor. She has been breast feeding without pain. <PAST MEDICAL HISTORY> PRENATAL COURSE *)EDC ___ by LMP and first trimester ultrasound *)A+/Ab-/RPRNR/RI/Hep B neg/HIV neg *)Hemoglobin elect. normal *)GC/CT negative *)Urine culture not performed *)Booking BP 100/60 *)Decreased risk ERA OBSTETRIC HISTORY G1 GYNECOLOGIC HISTORY Denies STIs. Sexually active in monogamous relationship with boyfriend, father of baby. PAST MEDICAL HISTORY denies PAST SURGICAL HISTORY denies <SOCIAL HISTORY> ___ <FAMILY HISTORY> non-contributory <PHYSICAL EXAM> On admission 102.3 116 117/72 12 100% RA Rigoring No cervical LAD No tonsilar injection or exudate Chest clear Tachy, RR Breast are non-tender, without engorgement or signs of mastitis Abd soft, NT, ND. Fundus NT. No rebound R CVAT No ___ tend No discharge Pelvic per ED staff, no mucoprurulent discharge <PERTINENT RESULTS> ___ 02: 00PM WBC-13.8* RBC-5.03 HGB-14.2 HCT-44.2# MCV-88 MCH-28.3 MCHC-32.1 RDW-13.5 ___ 02: 00PM PLT COUNT-248 ___ 02: 00PM GLUCOSE-83 UREA N-15 CREAT-0.9 SODIUM-128* POTASSIUM-7.6* CHLORIDE-95* TOTAL CO2-22 ANION GAP-19 ___ 02: 06PM LACTATE-2.2* K+-6.4* ___ 02: 06PM freeCa-0.88* ___ 06: 45PM CEREBROSPINAL FLUID (CSF) WBC-1 RBC-1* POLYS-3 ___ ___ 06: 45PM CEREBROSPINAL FLUID (CSF) PROTEIN-25 GLUCOSE-59 ___ 04: 24PM ___ PO2-69* PCO2-38 PH-7.40 TOTAL CO2-24 BASE XS-0 ___ 05: 25PM URINE UCG-NEGATIVE ___ 04: 00PM URINE BLOOD-MOD NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-MOD ___ 04: 00PM URINE ___ BACTERIA-FEW YEAST-NONE ___ BCx: Neg UCx: neg (after abx) CSF cx: neg CT head: There is no intracranial hemorrhage, mass effect, or gray-white matter differentiation abnormality. The ventricles and extra-axial spaces are within normal limits. There is no bony lesion to suggest malignancy or infection. Imaged paranasal sinuses and mastoid air cells are clear. CXR: No acute intrathoracic abnormality <MEDICATIONS ON ADMISSION> Motrin, tylenol PRN <DISCHARGE MEDICATIONS> 1. Cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q6H (every 6 hours) for 10 days. Disp: *40 Capsule(s)* Refills: *0* <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> Take your antibiotics as prescribed You can take tylenol and motrin for pain Call for: - fever (>100.4), chills - increasing pain - heavy vaginal bleeding - foul smelling vaginal discharge
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Ms. ___ was admitted from the emergency department with fever, flank pain, and a UA with +Leuk, +nit, +blood c/w pyelonephritis. In the ED she has a CT scan of her head as well as an LP ___ her complaints of HA and concern for possible meningitis, both of which were negative. Given recently postpartum, endometritis/ mastitis were on the differential however her exam was very reassuring and therefore these etiologies thought much less likely. Ms. ___ was started on IV ceftriaxone for pyelonephritis. Her Tmax was 103.5 ~ 6 hours after her first dose of antibiotics was given. Her fever curve then improved and she defervesced within 48 hours. Blood cultures were negative. The urine culture was intended to be sent in ED however this was not done. Repeat urine culture was obtained and was negative however this was after she was started on antibiotics. CSF cultures also returned negative. Once afebrile x 24 hours, she was transitioned to oral keflex. She was afebrile on keflex for 24 hours prior to discharge home. She was discharged on HD #4 in stable condition. She was afebrile and her CVAT improved. She was given a rx for keflex for an additional 10 days (14 day tx in total).
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10926172-DS-4
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> fever, rash <MAJOR SURGICAL OR INVASIVE PROCEDURE> none <HISTORY OF PRESENT ILLNESS> ___ yo G2P0 at 29w3d transferred from ED with fever, rash. She first noticed symptoms on ___, when she felt slightly "under the weather" and felt as if she were running a low grade fever. On ___, she felt worse, noted chills and diffuse arthralgias and presented to her PCP's office. A CBC was notable for mild thrombocytopenia, no leukocytosis, and normal LFTs. Lyme sergologies were sent. On ___, she agaain felt f/c, noted bilateral HA and malaise and went to urgent care where they felt this was likely a viral syndrome and did not recommend treatment. However, on arrival home she noticed a rash in her R inguinal region and called the on call physician for her PCP, who recommended starting treatment for possibly Lyme disease. She was prescribed 400 mg amoxicillin TID, took 1 dose prior to presentation. After starting antibiotics, she had a fever to 101.2 at home and decided to present to the ED. On arrival in the ED, she was afebrile but tachycardic to the 140s. Her HR decreased to 120s after 2 L IVF. She was then transferred to OB triage for further evaluation. On arrival, she noted fevers/chills. She noted a dry cough only when her fever spiked. Had mild neck pain/stiffness, full range of motion, no neuro deficit, no vision changes/facial droop/slurred speech. No URI sx, no productive cough, no wheezing. No abd pain. No n/v/d. No dysuria. No calf pain. No recent travel. No sick contacts. Has a pet dog at home, up to date on vaccinations. She notes the rash in her R inguinal fold feels "achy" at times, no pruritus. She is unsure if it is spreading as it is difficult for her to visualize. She denies ctx, VB, LOF. +FM. <PAST MEDICAL HISTORY> PNC: - ___ ___ by ___ - Labs Rh pos/Abs neg /Rub I /RPR NR /HBsAg neg /HIV neg /GBS unk - Screening: low risk Harmony - FFS normal anatomy - normal GLT - Issues: had lumbago/Rt buttock pain early in pregnancy s/p ___ eval OBHx: G2P0 - TAB x1 - G2: current GynHx: - denies abnormal Pap, fibroids, Gyn surgery, STIs PMH: R wrist fracture, basal cell carcinoma PSH: D&C, repair of R wrist fracture, removal of basal cell carcinoma <SOCIAL HISTORY> ___ <FAMILY HISTORY> non-contributory <PHYSICAL EXAM> (on admission) VS T 103 HR 143 BP 123/60 RR 18 98%RA repeat T 98.1 HR 120s Gen: A&O, appears mildly fatigued HEENT: no icterus, no LAD, no nuchal rigidity CV: mildly tachycardic, no murmurs/rubs PULM: CTAB Abd: soft, gravid, nontender SVE: deferred Ext: no calf tenderness, trace bilateral edema Skin: erythematous blanching area with well demarcated border extending from R inguinal fold to 4-5 cm inferior on anterior thigh, small <0.5 cm violaceous area in center, no induration or fluctuation, no vesicular lesions, no central lesions, skin otherwise clear, no petechiae Neuro: face symmetric, normal speech, CN II-XII, strength ___ all ext, sensation intact to light touch all ext, neg Kernigs and Brudinski's sign EKG (per ED review): sinus tachycardia Adequate pelvis Toco flat FHT 140/moderate varability/+accels/1 ? variable decel x 1 min at 0212, otherwise no decels <PERTINENT RESULTS> ___ WBC-7.5 RBC-3.44 Hgb-11.5 Hct-33.3 MCV-97 Plt-136 ___ Neuts-80.6 ___ Monos-7.9 Eos-0.3 Baso-0.3 ___ WBC-5.9 RBC-3.10 Hgb-10.0 Hct-31.1 MCV-100 Plt-137 ___ Neuts-64.0 ___ Monos-7.3 Eos-2.0 Baso-0.6 ___ WBC-5.8 RBC-3.23 Hgb-10.5 Hct-31.9 MCV-99 Plt-187 ___ Glu-120 BUN-7 Creat-0.5 Na-134 K-3.3 Cl-102 HCO3-20 ___ ALT-64 AST-42 AlkPhos-98 TotBili-0.3 ___ ALT-61 AST-37 ___ ALT-53 AST-29 LD(LDH)-173 ___ Albumin-2.9 ___ Lactate-1.2 ___ 07: 45AM BLOOD Parst S-NEG ___ 10: 00 BABESIA MICROTI DNA PCR Results Pending ___ 10: 00 ANAPLASMA PHAGOCYTOPHILUM (HUMAN GRANULOCYTIC EHRLICHIA AGENT) IGG/IGM Results Pending URINE CULTURE (Final ___: <10,000 organisms/ml. Blood Culture, Routine (Pending): <MEDICATIONS ON ADMISSION> prenatal vitamins <DISCHARGE MEDICATIONS> 1. Prenatal Vitamins 1 TAB PO DAILY 2. Amoxicillin 500 mg PO Q8H RX *amoxicillin 500 mg 1 capsule(s) by mouth three times a day Disp #*57 Capsule Refills: *0 <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> pregnancy at 29w5d fever <DISCHARGE CONDITION> stable <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> You were admitted to the antepartum service for further evaluation of your fever, malaise, and R groin rash. The ID team was consulted and followed you closely. The exact etiology of your fever is unclear, possibly a tick-borne illness. The rash may be a cellulitis and may need further antibiotics. You will continue Amoxicillin to treat possible Lyme infection. Although your Lyme test was negative, its possible that you got tested too early. You can get retested for Lyme in 2 weeks. You were tested for other tick-borne illnesses as well and these studies were still pending at the time of discharge. On admission, there was concern for a possible fetal cardiac arrhythmia. You were evaluated in the ___ Maternal Fetal Medicine and ultrasound was normal.
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___ y/o G2P0 at 29w3d admitted for further workup of fever, malaise, and rash. . *) fever/rash: Ms ___ was febrile to 103 and tachycardic to the 140s on admission. She had a normal WBC, but had a mild transaminitis. A malaria smear was negative. ID was consulted and followed her closely. It was felt that the most likely etiology was a tick-borne illness. Lyme serologies which had been sent prior to this admission returned negative, however, may have been drawn too early. She was initially treated with IV Vancomycin and Ceftriaxone. Babesia and Anaplasma serologies were ordered and were pending at the time of discharge. Her rash was monitored and appeared stable. Her fever resolved quickly and she remained afebrile for the remainder of this admission. She reported an intermittent headache, but didn't have any meningeal signs on exam. Her transaminitis improved and blood cultures were negative. The Vancomycin was discontinued on HD#2. On HD#3, the IV Ceftriaxone was discontinued and she was transitioned to po Amoxicillin. She will complete a 3 week course for possible Lyme disease and will have close outpatient followup and likely repeat Lyme serologies in 2 weeks. . Ms ___ had no obstetrical concerns during this admission. There was suspicion for a possible fetal arrythmia which was audible on admission. She was seen in the ___ on ___ and had an unremarkable ultrasound.
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10926423-DS-18
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Penicillins <ATTENDING> ___ <CHIEF COMPLAINT> Term pregnancy and h/o pulmonary embolism in this pregnancy <MAJOR SURGICAL OR INVASIVE PROCEDURE> None <HISTORY OF PRESENT ILLNESS> A ___ y.o. at 38 weeks admitted for IOL. Is on 80mg BID of Lovenox for h/o pulmonary embolism in this pregnancy. <PAST MEDICAL HISTORY> Pulmonary embolism diagnosed in this pregnancy. Treated with 80mg of Lovenox BID <PHYSICAL EXAM> Afeb, VSS Abd: gravid Ext: no CCE <PERTINENT RESULTS> ___ 09: 53PM URINE COLOR-Yellow APPEAR-Hazy SP ___ ___ 09: 53PM URINE BLOOD-SM NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 LEUK-MOD <MEDICATIONS ON ADMISSION> Lovenox 80mg BID <DISCHARGE MEDICATIONS> 1. oxycodone-acetaminophen ___ mg Tablet Sig: ___ Tablets PO every ___ hours as needed for Pain for 10 days. Disp: *60 Tablet(s)* Refills: *0* 2. ibuprofen 600 mg Tablet Sig: One (1) Tablet PO every eight (8) hours as needed for Pain for 10 days. Disp: *40 Tablet(s)* Refills: *0* <DISCHARGE DISPOSITION> Home With Service Facility: ___ <DISCHARGE DIAGNOSIS> Term pregnancy, delivered. NVD <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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Ms. ___ had an uneventful labor and delivered a healthy girl over 2nd degree perineal tear. Restarted on Lovenox 80mg BID 12hrs after the delivery. She recovered uneventfully and was discharged on PPD 2.
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10929406-DS-16
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> "Bartholin's cyst" <MAJOR SURGICAL OR INVASIVE PROCEDURE> None while hospitalized (drainage of cyst in emergency department prior to admission) <HISTORY OF PRESENT ILLNESS> ___ yo G___ who presents with bleeding from a previously incised and drained right ___'s cyst. About a week ago she noted pain and swelling in the right labia. She was seen by her PCP who gave her a perscription for amoxicillin. This did not result in improvement and she was sent to the ED for further management. The night prior to presentation, ED staff drained the Bartholin's cyst and placed a Word catheter. She now returns to the ED with profuse bleeding from the site soaking several pads and running down her leg. On arrival, the ED staff removed the Word catheter for further exploration of the site and asked the GYN resident on call to come evaluate the patient. Prior to evaluation, they tried injecting the site with lidocaine with epinephrine as well as placing surgicell over the site. She has a history of recurrent Bartholin's cyst abscesses. All five of her prior episodes were right-sided and treated in ___. For each episode she was treated with surgery per patient and she never had a catheter left in place. She has never had antibiotics until this week. On presentation, she is in significant discomfort at the site. She received percocet for pain in the ED. Denies fevers, chills, sweats. <PAST MEDICAL HISTORY> - Open Left salpingectomy for ectopic pregnancy <SOCIAL HISTORY> ___ <FAMILY HISTORY> Noncontributory <PHYSICAL EXAM> Initial Physical Examination was performed by Dr. ___ VS: 98 81 119/70 18 100% Gen: Well No acute distress Abd: Soft, Non-tender, no masses. Well healed Phannensteil skin incision. Pelvic: 5-10mm skin incision made on the medial aspect of the edematous right labia. When milked there is significant dark red bleeding and pus draining from the site. This remains significantly tender. Ext: Non-tender, non-edematous <PERTINENT RESULTS> ___ 02: 50AM GLUCOSE-105* UREA N-8 CREAT-0.6 SODIUM-139 POTASSIUM-3.5 CHLORIDE-106 TOTAL CO2-20* ANION GAP-17 ___ 02: 50AM estGFR-Using this ___ 02: 50AM HCG-<5 ___ 02: 50AM WBC-9.0 RBC-4.00* HGB-12.3 HCT-34.8* MCV-87 MCH-30.6 MCHC-35.2* RDW-12.2 ___ 02: 50AM NEUTS-78.8* LYMPHS-12.7* MONOS-5.5 EOS-2.7 BASOS-0.3 ___ 02: 50AM PLT COUNT-284 ___ 02: 50AM ___ PTT-23.2 ___ <MEDICATIONS ON ADMISSION> - Oral contraceptive pills <DISCHARGE MEDICATIONS> 1. Bactrim DS 800-160 mg Tablet Sig: One (1) Tablet PO twice a day for 7 days. Disp: *14 Tablet(s)* Refills: *0* 2. ZOFRAN ODT 4 mg Tablet, Rapid Dissolve Sig: One (1) Tablet, Rapid Dissolve PO every eight (8) hours as needed for nausea. Disp: *30 Tablet, Rapid Dissolve(s)* Refills: *0* 3. Percocet ___ mg Tablet Sig: ___ Tablets PO every four (4) hours as needed for pain. Disp: *30 Tablet(s)* Refills: *0* 4. Motrin 600 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for pain. Disp: *60 Tablet(s)* Refills: *0* <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> bartholin's gland cyst <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> You will have a packing in place. Leave as is. Take your antibiotics as prescribed. Use ___ baths 4 times daily (soak in warm water x 10 minutes 4 times daily). You can take the pain medications as prescribed. Do not drive while taking narcotics. Please call ___ if you should develop fevers, chills, significant increase in pain, inability to tolerate your medications.
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Ms ___ was admitted into the gynecology service for possible marsupialization of bartholin's cyst. She was started on Gentamicin and Clindamicin, which were discontined on the same day. On evaluation of cyst by attending, it was decided that there was no need for surgical management during current hospitalization as the cyst had drained and there was no residual fluctuence. Patient was to follow up with Dr. ___ further evaluation. Ms ___ was discharged on hospital day 1 with a prescription bactrim for 7 days. She was also told to perform ___ bath four times a day lasting 10 minutes.
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10932005-DS-6
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> not feeling well <MAJOR SURGICAL OR INVASIVE PROCEDURE> none <HISTORY OF PRESENT ILLNESS> Ms. ___ is a ___ year old G6P3 at ___ who presented to a prenatal visit this morning not feeling well. She had been seen yesterday at a hospital in ___, where she was having nausea and diarrhea. She was given IV fluids at the time. She was also having some neck and back pain, but had recently been in a motor vehicle accident on ___. She had not sought care following the MVA. She has been feeling some "rock hard" feeling in RLQ +AFM, no LOF. No VB. <PAST MEDICAL HISTORY> PNC: - ___: ___ - Labs: A+/ab neg/RPRNR/RI/HIV neg/HepBsAg neg/HCV neg - Screening: LR ERA - FFS: wnl - GLT: wnl - Issues: use of multiple SSRIs in pregnancy, for growth scan tomorrow (___) PMH: fibromyalgia, depression/anxiety, asthma PSH: D&C OBH: ___ - SAB with D&C ___ - SVD, term, uncomplicated ___ - SVD, term, uncomplicated ___ - SVD, term, sciatica ___ - EAB, 8 weeks, medical GynH: +h/o abnormal Paps, no cervical procedures <SOCIAL HISTORY> ___ <FAMILY HISTORY> non-contributory <PHYSICAL EXAM> (on admission) Afebrile, HR ___, BP 110/80s Gen: NAD Lungs: CTAB CV: RRR Abd: slightly tender to palpation RLQ Back: Slight right sided +CVAT per Dr. ___ SVE: 1/long/high per Dr. ___ from exam in office) FHT: 120s/mod var/+accels/no decels TOCO: q2-4 min -> spaced TAUS: BPP ___, per Dr. ___ ___ Results: ___ WBC-7.9 RBC-4.13 Hgb-11.6 Hct-36.1 MCV-87 Plt-207 ___ Neuts-68.3 ___ Monos-6.5 Eos-2.2 Baso-0.3 ___ URINE Blood-NEG Nitrite-NEG Protein-100 Glucose-TR Ketone-40 Bilirub-NEG Urobiln-2 pH-6.5 Leuks-TR ___ URINE RBC-4 WBC-7 Bacteri-MOD Yeast-NONE Epi-78 ___ URINE bnzodzp-NEG barbitr-NEG opiates-NEG cocaine-NEG amphetm-NEG mthdone-NEG URINE CULTURE (Final ___: MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION. <MEDICATIONS ON ADMISSION> The Preadmission Medication list is accurate and complete. 1. Fluticasone Propionate 110mcg 2 PUFF IH BID 2. Albuterol Inhaler ___ PUFF IH Q6H: PRN wheezes 3. Montelukast 10 mg PO DAILY 4. Prenatal Vitamins 1 TAB PO DAILY 5. Acetaminophen 325-650 mg PO Q6H: PRN pain 6. Nitrofurantoin Monohyd (MacroBID) 100 mg PO Q12H <DISCHARGE MEDICATIONS> 1. Albuterol Inhaler ___ PUFF IH Q6H: PRN wheezes 2. Fluticasone Propionate 110mcg 2 PUFF IH BID 3. Montelukast 10 mg PO DAILY 4. Prenatal Vitamins 1 TAB PO DAILY 5. Acetaminophen 650 mg PO Q6H: PRN Pain 6. Nitrofurantoin Monohyd (MacroBID) 100 mg PO Q12H <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> possible urinary tract infection, viral infection. <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> You were admitted to the hospital for preterm contractions, malaise, nausea, possible urinary tract infection. You were given 1 dose of IV antibiotic (Ceftriaxone) and then continue on Macrobid. You felt better after IV fluid and able to eat. The pain improved. Your contractions resolved. The cervical exam remained stable and you are now safe to be discharged home. Please finish the Macrobid as prescribed.
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___ y/o G6P3 admitted at 32w6d with general malaise, lower abdominal pain, ? dehydration vs UTI. She was admitted for hydration and supportive care. She received one dose of Ceftriaxone due to CVA tenderness. However, she was switched back to po Macrobid on HD#2 given no further concern for pyelonephritis (afebrile, normal WBC). Her urine culture was only positive for mixed flora. . She had reassuring fetal testing in the CMFM and was overall symptomatically improved on HD#2. She was discharged home in stable condition at that time.
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10932447-DS-15
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> vaginal bleeding <MAJOR SURGICAL OR INVASIVE PROCEDURE> none <HISTORY OF PRESENT ILLNESS> She is a ___ yo G3P2002 @ 27w5d by LMP c/w 12 wk US with pregnancy complicated by AMA, asymptomatic short cervix, two prior cesarean deliveries. She states that last night at 2300 she felt a gush of fluid soaking her underwear andpants and running down her leg. She went to the bathroom and found it was blood. She put on a pad and checked ___ hour later and there was no further bleeding. SHe did have some mild cramping following the bleeding, but this has resolved. Since she has not had any further bleeding, cramping, LOF. Good FM. she otherwise feels well, no spotting, cramping, CP/SOB or headache. The remainder of the review of symptoms is negative. <PAST MEDICAL HISTORY> ObHx: ___ LTCS at 42w 7#7oz, ___ stage arrest ___ LTCS at 41w 7#6oz, ___ stage arrest, followed for short cervix and got betamethasone. Had injury to dome of bladder, repaired GynHx: Regular periods, no h/o STD, PID, abnl pap. PMH: seasonal allergies PSH: C/S x2 with bladder injury (dome bladder) <SOCIAL HISTORY> ___ <FAMILY HISTORY> No known history of Downs syndrome, chromosomal abnormalities, learning disability or birth defects. No clotting/bleeding disorders. <PHYSICAL EXAM> On admission: ___ 11: 24 Temp.: 98.5°F ___ 11: 24 Resp.: 14 / min ___ 11: 24 BP: 93/62 (70) ___ ___ MHR: 97 SVE: closed/50/soft/mid SSE: very small amt tan discharge with a tiny bit of pink mixed in. No other fluid or discharge. No active bleeding. Cervix appears smooth. FHT: 135/mod/+accels/no decels/ reactive Toco: irreg contractions q ___ min On depression: Vitals: ___ 2222 Temp: 98.4 PO BP: 118/74 HR: 106 RR: 18 O2 sat: 96% O2 delivery: ra Pain Score: ___ Fetal Monitoring: FHR: 145 FM: Present Gen: [x] NAD Resp: [x] No evidence of respiratory distress Abd: [x] soft [x] non-tender Ext: [x] no edema [x] non-tender Date: ___ Time: 0915 FHT: 145/mod var/10x10 accels/rare variable decel Toco: rare ctx Date: ___ Time: ___ FHT: 145/mod var/10x10 accels/one variable decel Toco: rare ctx <PERTINENT RESULTS> -= LABS -= ___ 04: 12PM BLOOD WBC-12.3* RBC-3.78* Hgb-10.0* Hct-31.0* MCV-82 MCH-26.5 MCHC-32.3 RDW-14.1 RDWSD-40.6 Plt ___ ___ 05: 31PM URINE bnzodzp-NEG barbitr-NEG opiates-NEG cocaine-NEG amphetm-NEG oxycodn-NEG mthdone-NEG -= ULTRASOUND -= ___: EFW 1207 g, 61st %. Normal brain, heart, GI tract/stomach, urogenital tract/kidneys/bladder. Cervical length 1.5 mm with funneling. BPP ___. Posterior placenta. Cephalic. Normal fluid. <MEDICATIONS ON ADMISSION> progesterone vaginal PNV <DISCHARGE MEDICATIONS> 1. Nitrofurantoin Monohyd (MacroBID) 100 mg PO Q24H RX *nitrofurantoin monohyd/m-cryst 100 mg 1 capsule(s) by mouth once daily Disp #*30 Capsule Refills: *2 2. Acetaminophen 650 mg PO Q6H: PRN Pain 3. Calcium Carbonate 500 mg PO QID: PRN Dyspepsia 4. Docusate Sodium 100 mg PO BID: PRN Constipation 5. Prenatal Gummy (PNV62-FA-om3-dha-epa-fish oil) 2 GUM ORAL DAILY 6. proGESTerone micronized 200 mg VG QHS <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> likely placental abruption, short cervix, history of urinary tract infections <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 vaginal bleeding concerning for abruption. You were monitored for 5 days without any evidence of further vaginal bleeding. 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. You have a history of a short cervix, which was measuring about 1.5 cm on our ultrasounds. Please continue your vaginal progesterone as prescribed. Given your history of urinary tract infections, you will be placed on a daily antibiotic to prevent further infections from occurring. Please call your doctor with any symptoms of burning with urination, bloody urine, flank pain, fevers or chills. Please follow the instructions below: - Attend all appointments with your obstetrician and all fetal scans - Monitor for the following danger signs: - headache that is not responsive to medication - abdominal pain - increased swelling in your legs - vision changes - Worsening, painful or regular contractions - Vaginal bleeding - Leakage of water or concern that your water broke - Nausea/vomiting - Fever, chills - Decreased fetal movement - Other concerns
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Ms. ___ is a ___ year old G3P2 pregnancy complicated by AMA, asymptomatic short cervix, two prior cesarean deliveries who was admitted to the Antepartum service with vaginal bleeding concerning for placental abruption. On admission, she was hemodynamically stable without active bleeding. She had no evidence of preterm labor and fetal testing was reassuring. Ultrasound in the ___ showed no sonographic evidence of abruption and a cervical length of 1.5cm. She received a course of betamethasone (complete ___ and the NICU was consulted. She was continued on vaginal progesterone while she was here. She remained clinically stable without any bleeding and was discharged to home on ___. She will have close outpatient follow up. Of note, Ms ___ had 2 prior UTIs during the pregnancy. Her urine culture here grew only mixed flora. She was started on Macrobid suppression which she will continue for the remainder of the pregnancy.
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10932815-DS-4
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> Grade I endometrial cancer. <MAJOR SURGICAL OR INVASIVE PROCEDURE> TOTAL LAPAROSCOPIC HYSTERECTOMY, BILATERAL SALPINGECTOMY, REMOVAL OF IUD, PELVIC WASHINGS <PHYSICAL EXAM> PHYSICAL EXAM AT DISCHARGE -========= Temp: 99.5 (Tm 99.5), BP: 126/74 (107-126/65-74), HR: 83 (75-103), RR: 18 (___), O2 sat: 96% (95-100), O2 delivery: RA 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 Incision: 4 LSC port sites across abdomen, c/d/i without surround erythema or induration Dressings: taken down, steris remain GU: foley absent, no spotting on pad Extremities: no calf tenderness, wwp, pboots on and active bilaterally <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. ___ ("Apple") was admitted to the gynecologic oncology service after undergoing TOTAL LAPAROSCOPIC HYSTERECTOMY, BILATERAL SALPINGECTOMY, REMOVAL OF IUD, PELVIC WASHINGS. Please see the operative report for full details. Her post-operative course is detailed as follows. Immediately postoperatively, her pain was controlled with PO oxycodone/acetaminophen/ibuprofen with IV morphine for breakthrough. Her diet was advanced without difficulty. On post-operative day #1, her urine output was adequate so her Foley catheter was removed and she voided spontaneously. By post-operative day 1, she was tolerating a regular diet, voiding spontaneously, ambulating independently, and pain was controlled with oral medications. She was then discharged home in stable condition with outpatient follow-up scheduled. Discharge Medications: 1. Acetaminophen ___ mg PO Q6H:PRN Pain - Mild RX *acetaminophen [Acetaminophen Extra Strength] 500 mg ___ tablet(s) by mouth every 6 hours as needed Disp #*50 Tablet Refills:*2 2. Docusate Sodium 100 mg PO BID:PRN constipation RX *docusate sodium 100 mg 1 capsule(s) by mouth twice per day Disp #*30 Capsule Refills:*2 3. Ibuprofen 600 mg PO Q6H:PRN Pain - Moderate RX *ibuprofen 600 mg 1 tablet(s) by mouth every 6 hours as needed Disp #*50 Tablet Refills:*2 4. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain - Severe RX *oxycodone 5 mg 1 tablet(s) by mouth every 4 hours as needed Disp #*20 Tablet Refills:*0 Discharge Disposition: Home Discharge Diagnosis: endometrial cancer Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___
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10933203-DS-19
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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> D&C Bakri balloon placement Transfusion of 5 units pRBC's and 1 unit FFP Arterial line <HISTORY OF PRESENT ILLNESS> ___ yo G1P0 at 39w2d with painful contractions. Has bloody show. No LOF. +FM. No fevers. <PAST MEDICAL HISTORY> PNC: - ___ ___ by LMP - Labs Rh+/Abs-/Rub immune/RPR NR/HBsAg neg/HIV neg/GBS neg - Screening: CF negative, low risk Quad. Missed ERA appointment - FFS: Normal w/ limited aortic arch views. Normal ECHO at CHB. Low lying placenta resolved. - GLT: 101 - Issues: Fetal pyelectasis noted on imaging in ___ on ___. Continues to be noted on ___ ultrasound. EFW on ___ (52%) OBHx: - G1 GynHx: - No h/o fibroids, Gyn surgery, GC/Chl negative. No h/o abnormal Paps due to young age. PMH: Asthma with rescue inhaler (no hx of intubations), anemia on iron supplement, recurrent UTIs (not currently taking suppression). PSH: None <SOCIAL HISTORY> Denies T/E/D. High school student in ___. FOB college student, in relationship 7 months. Lives with mother. Supported by mother and family of FOB. <PHYSICAL EXAM> On discharge: Gen: NAD Resp: breathing comfortably CV: RRR Abd: soft, appropriately tender, no rebound/guarding Lochia: minimal Ext: no TTP <PERTINENT RESULTS> ___ 09: 30AM BLOOD WBC-11.6* RBC-3.87* Hgb-10.7* Hct-32.5* MCV-84# MCH-27.6 MCHC-32.9 RDW-13.0 RDWSD-39.3 Plt ___ ___ 09: 39PM BLOOD WBC-19.4*# RBC-3.09* Hgb-8.9* Hct-26.9* MCV-87 MCH-28.8 MCHC-33.1 RDW-13.9 RDWSD-42.9 Plt ___ ___ 10: 17PM BLOOD WBC-21.0* RBC-4.24# Hgb-12.6# Hct-36.6# MCV-86 MCH-29.7 MCHC-34.4 RDW-13.4 RDWSD-41.6 Plt ___ ___ 06: 00AM BLOOD WBC-17.2* RBC-3.60* Hgb-10.6* Hct-30.3* MCV-84 MCH-29.4 MCHC-35.0 RDW-13.6 RDWSD-41.5 Plt ___ ___ 12: 30PM BLOOD WBC-14.8* RBC-3.54* Hgb-10.5* Hct-29.9* MCV-85 MCH-29.7 MCHC-35.1 RDW-14.0 RDWSD-43.1 Plt ___ ___ 09: 39PM BLOOD ___ PTT-33.1 ___ ___ 12: 30PM BLOOD ___ PTT-29.0 ___ ___ 09: 39PM BLOOD ___ ___ 10: 17PM BLOOD ___ 06: 00AM BLOOD ___ 12: 30PM BLOOD ___ 09: 43PM BLOOD Type-ART pO2-291* pCO2-26* pH-7.34* calTCO2-15* Base XS--9 ___ 09: 43PM BLOOD Lactate-5.3* ___ 09: 43PM BLOOD freeCa-0.95* <MEDICATIONS ON ADMISSION> PNV, albuterol inhaler prn <DISCHARGE MEDICATIONS> 1. Docusate Sodium 100 mg PO BID: PRN Constipation 2. Ibuprofen 600 mg PO Q6H: PRN pain 3. Sarna Lotion 1 Appl TP TID: PRN rash <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> s/p vaginal delivery on ___. Girl postpartum hemorrhage secondary to uterine atony disseminated intravascular coagulopathy (DIC) <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Please see OB discharge packet. Pelvic rest and no heavy lifting x 6 weeks
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On ___, this ___ year old G1P0 at 39+2 weeks presented in labor and had a spontaneous vaginal delivery on ___. Her delivery was complicated by postpartum hemorrhage and disseminated intravascular coagulopathy. She had an estimated blood loss of 4000cc due to uterine atony and was taken back to the OR for a D&C and placement of Bakri balloon. Please see the operative report for more details. . She was given Pitocin, cytotec, and methergine IM, as well as 24 hours of oral methergine postpartum. Her pre-operative hematocrit was 32.5%, and decreased to 26.9% intra-op. Massive transfusion protocol was active and she was given 5 units of packed red blood cells and 1 unit of fresh frozen plasma. Her post-operative hematocrit was 36.6% immediately and then 30.0% and she remained hemodynamically stable and no further labs were sent. The Bakri balloon with 300cc of fluids was placed with vaginal packing and foley catheter at 2100 on ___ and these were removed the morning of ___, with minimal vaginal bleeding subsequently. She received 24 hours of kefzol postpartum. She initially had an arterial line and external jugular line for monitoring intra-op, which were not required following the OR case. Her pain was initially controlled with an epidural, and she was transitioned to oral oxycodone, Tylenol, and ibuprofen once her diet was advanced to regular without difficulty. . She otherwise had an uncomplicated postpartum course and was discharged on postpartum day ___ontrolled on oral medications, voiding spontaneously, ambulating independently, and minimal and stable vaginal bleeding.
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10933988-DS-6
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> Pelvic pain <MAJOR SURGICAL OR INVASIVE PROCEDURE> None <HISTORY OF PRESENT ILLNESS> ___ G0 with known large fibroid uterus and recent admission to heme service for likely necrotizing lymphadenitis who presents with worsening abdominal pain today. She reports that this morning she was sitting on the toilet, straining to have a bowel movement, and gradually develooed lower abdominal pain in her infraumbilical abdomen as well as spasming rectal pain that became very severe. Became nauseous, had one episode of emesis. . Subsequently pain improved but she continues to have waves of pain that feel like cramping in lower abdomen. No laterality to pain, but positional; pain feels better when she is laying on her right side. Nausea improved, no further episodes of emesis. LMP ___, finished her period 3 days ago. No vaginal bleeding or abnormal discharge today. . Was recently admitted to hospital for work-up of cervical lymphadenopathy and fever. Underwent biopsy with pathology notable for histiocytic necrotizing lymphadenitis of ___. HIV, EBV, CMV, HHV6 negative. Is being followed by rheumatology and ID. . Patient was seen in ___ clinic by Dr. ___ on ___ and counseled re options for fibroid mgmt. Received 1 dose of 3mo course of lupron, with plan to go to OR for D&C for endometrial sampling in next few months and abdominal myomectomy after ___ courses of lupron. . ROS notable for constipation. Last BM was 2 days ago but was small, hard stool and complains of straining. Has had irregular bowel movements, with periods of constipation, for past 4 weeks since her fall. Is taking a stool softener intermittently. . Denies fevers, chills, night sweats, lightheadedness, dizzines, chest pain, shortness of breath. Endorses feeling anxious about her fibroid and all of her medical issues going on. Denies recent abdominal trauma or fall or domestic violence. ROS otherwise negative. <PAST MEDICAL HISTORY> ObHx: GO . GYN Hx: LMP ___ Menarche age ___ q28d x 5 days, +menorrhagia. No dysmenorrhea. Last Pap ___ negative per pt report, no history of abnormal. Denies history of STI. Female partner. No contraception. Large fibroid uterus, s/p 3mo course of lupron ___ Last CT scan ___ with 33.4 x 17.3 x 24.4cm uterus, 22.1cm superior dominant fibroid, heterogenous with some internal degeneration, no calcifications, mass effect on bladder and surrounding large bowel with no evidence of obstruction. . PMH: obesity (BMI 48), OSA, likely necrotizing lymphadenitis . PSH: wisdom teeth, knee surgery . All: NKDA <SOCIAL HISTORY> ___ <FAMILY HISTORY> Non-contributory <PHYSICAL EXAM> Afebrile, VSS NAD, comfortable Lungs CTAB CV: RRR Abdomen soft, NTND, no r/g Ext: no erythema or swelling, NTTP <PERTINENT RESULTS> ___ 07: 20AM BLOOD WBC-7.8 RBC-4.38 Hgb-12.6 Hct-37.4 MCV-85 MCH-28.9 MCHC-33.8 RDW-13.8 Plt ___ ___ 07: 20AM BLOOD Neuts-51.0 ___ Monos-7.2 Eos-2.5 Baso-0.5 ___ 07: 20AM BLOOD Glucose-106* UreaN-9 Creat-0.8 Na-134 K-6.1* Cl-100 HCO3-19* AnGap-21* ___ 07: 16AM BLOOD Glucose-106* Lactate-3.5* K-4.9 ___ 05: 14PM BLOOD Lactate-1.1 . ___ 04: 24AM URINE Color-Yellow Appear-Clear Sp ___ ___ 04: 24AM URINE Blood-NEG Nitrite-NEG Protein-100 Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-2* pH-6.0 Leuks-NEG ___ 04: 24AM URINE RBC-0 WBC-4 Bacteri-FEW Yeast-NONE Epi-2 ___ 08: 45AM URINE CastHy-2* . ___ 4: 24 am URINE Source: ___. URINE CULTURE (Pending): <MEDICATIONS ON ADMISSION> ativan prn nausea <DISCHARGE MEDICATIONS> 1. Acetaminophen 1000 mg PO Q6H: PRN pain 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 every 12 hours Disp #*60 Tablet Refills: *0 3. HYDROmorphone (Dilaudid) ___ mg PO Q4H: PRN pain RX *hydromorphone 2 mg ___ tablet(s) by mouth every 4 - 6 hours Disp #*40 Tablet Refills: *0 4. Ibuprofen 600 mg PO Q6H: PRN pain RX *ibuprofen 600 mg 1 tablet(s) by mouth every 6 hours Disp #*60 Tablet Refills: *1 5. Bisacodyl ___AILY RX *bisacodyl 10 mg 1 suppository(s) rectally daily Disp #*30 Suppository Refills: *0 <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> Fibroid pain Constipation <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Dear Ms. ___, You were admitted into the gynecology service for pain control likely from degenerating fibroid as well as constipation. Your pain is now controlled on pain meds and the team feels that you can be discharged home. *) We will schedule a follow up appointment for you within the next ___ weeks *) A consult appointment has been made for you with interventional radiology to discuss alternative management of your fibroids. They will contact you via phonecall.
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On ___, Ms. ___ was admitted to the Gynecology service for management of pelvic pain likely secondary to fibroid degeneration and constipation. . For her pain, she was initially placed on IV toradol, PO acetaminophen, PO dilaudid, and IV dilaudid for breakthrough pain. She was also placed on an aggressive bowel regimen of colace, miralax, and dulcolax suppository. . By hospital day 2, her pain was controlled with oral medications and she had a bowel movement during her hospitalization. She was discharged home in stable condition with outpatient follow up scheduled.
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10934681-DS-21
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> endometrial carcinoma <MAJOR SURGICAL OR INVASIVE PROCEDURE> total laparoscopic hysterectomy, converted to exploratory laparotomy, completion of abdominal hysterectomy, bilateral salpingo-oophorectomy, with repair of a right ureteral transection with right neoureterocystotomy, placement of right ureteral stent, rectosigmoid resection with protective diverting loop ileostomy <HISTORY OF PRESENT ILLNESS> Ms. ___ is a ___ yo G4P2 post-menopausal female with hypertension, diabetes, and obesity who experienced 1 day of light vaginal bleeding in ___. This was the first time since menopause that she experienced vaginal bleeding. She presented to her gynecologist, who performed an endometrial biopsy, which was notable for a Grade 1 endometroid endometrial cancer. Given this finding, she was referred to ___ clinic. Of note, she has been on premarin for over a decade. She presents today for scheduled total laparoscopic hysterectomy with bilateral salpingo-oophorectomy for endometrial cancer. <PAST MEDICAL HISTORY> - T2DM (followed at ___, on metformin and humalog ___ pen). A1C 8.8 - Hypertension (on amlodipine, atenolol, valsartan-HCTZ and furosemide) - Cardiac catheterization for unclear finding, with subsequent finding of normal coronary arteries and no stunting performed -Hyperlipidemia -Ejection fraction 65%, trace triscuspid valve regurgitation from echo in ___ - She denies any personal history of asthma, venous thromboembolism, or stroke. surgical history: open cholecystectomy obstetrical history: G4P2, post-menopausal, previously has had regular periods and dysmenorrhea. Denies history of fibroids, cysts, STDs, abnormal pap smears. Not currently sexually active <SOCIAL HISTORY> ___ <FAMILY HISTORY> Colon cancer in brother, possible breast cancer in mother. <PHYSICAL EXAM> On admission: Temp 98, pulse 68, respiratory rate 16, blood pressure 158/94, 98% O2 Sat on RA Ht 160cm, Wt 83kg. blood glucose 177 CV: RRR, no appreciable murmurs Resp: Bilaterally clear to auscultation Abdomen: Soft NT/ND, no palpable masses, scar from previous cholecystectomy in right upper quadrant, well healed Ext: 1+ edema noted in ankles bilaterally On day of discharge: Afebrile, vitals stable No acute distress CV: regular rate and rhythm Pulm: clear to auscultation bilaterally Abd: soft, appropriately tender, nondistended, no rebound/guarding, laparoscopy incisions clean/dry/intact, midline incision with wet to dry packing in place, scar from previous cholecystectomy in right upper quadrant, well healed Ostomy: pink mucosa, patent, productive ___: nontender, nonedematous <PERTINENT RESULTS> ___ abdominal XR Double-J stent in appropriate position, in the right kidney ___ CXR There are low lung volumes. Mild Cardiomegaly is stable. Bilateral effusions are small and associated with adjacent atelectasis. There is mild vascular congestion ___ abd/pelvic CT 1. A small amount of fluid and gas subjacent to and communicating with the midline laparotomy wound, and extending into the pelvis, has not yet organized. Superinfection cannot be excluded by imaging. 2. Post low anterior resection with diverting loop ileostomy. No bowel obstruction. 3. Right nephroureteral stent in appropriate position. 4. Small bilateral pleural effusions with adjacent compressive atelectasis. ___ cystogram No evidence of bladder leak or reflux. ___ abd/pelvic CT 1.Minimal decrease in size of non-organized fluid collections adjacent and communicating with the midline vertical incision with redemonstration of extension into the left hemipelvis. 2. Status post low anterior resection with diverting ileostomy without evidence of obstruction. 3. Right ureteral stent remains in place. ___ 06: 15AM BLOOD WBC-8.8 RBC-3.68* Hgb-10.2* Hct-32.3* MCV-88 MCH-27.7 MCHC-31.6 RDW-16.9* Plt ___ ___ 05: 35AM BLOOD WBC-9.4 RBC-3.47* Hgb-9.7* Hct-30.7* MCV-88 MCH-27.9 MCHC-31.6 RDW-16.7* Plt ___ ___ 05: 42AM BLOOD WBC-9.3 RBC-3.56* Hgb-9.8* Hct-31.4* MCV-88 MCH-27.6 MCHC-31.2 RDW-17.1* Plt ___ ___ 05: 41AM BLOOD WBC-10.7 RBC-3.49* Hgb-9.8* Hct-30.9* MCV-89 MCH-28.1 MCHC-31.8 RDW-17.4* Plt ___ ___ 05: 55AM BLOOD WBC-12.9* RBC-3.64* Hgb-9.9* Hct-32.3* MCV-89 MCH-27.2 MCHC-30.7* RDW-17.4* Plt ___ ___ 06: 07AM BLOOD WBC-15.4* RBC-3.67* Hgb-10.4* Hct-32.4* MCV-88 MCH-28.3 MCHC-32.1 RDW-17.3* Plt ___ ___ 06: 15AM BLOOD WBC-13.8* RBC-3.57* Hgb-10.0* Hct-31.2* MCV-87 MCH-28.1 MCHC-32.2 RDW-17.5* Plt ___ ___ 06: 20AM BLOOD WBC-13.7* RBC-3.49* Hgb-9.8* Hct-30.7* MCV-88 MCH-28.1 MCHC-32.0 RDW-17.3* Plt ___ ___ 06: 30AM BLOOD WBC-12.0* RBC-3.53* Hgb-9.9* Hct-30.8* MCV-87 MCH-28.1 MCHC-32.3 RDW-16.6* Plt ___ ___ 06: 10AM BLOOD WBC-13.6* RBC-3.85* Hgb-10.9* Hct-33.6* MCV-87 MCH-28.2 MCHC-32.4 RDW-16.2* Plt ___ ___ 06: 15AM BLOOD WBC-16.0* RBC-3.45* Hgb-9.8*# Hct-30.2* MCV-87 MCH-28.4 MCHC-32.5 RDW-16.0* Plt ___ ___ 08: 20AM BLOOD WBC-11.7* RBC-2.81* Hgb-7.6* Hct-24.3* MCV-86 MCH-26.9* MCHC-31.2 RDW-16.0* Plt ___ ___ 01: 00AM BLOOD WBC-10.8 RBC-2.99* Hgb-8.1* Hct-25.7* MCV-86 MCH-27.2 MCHC-31.7 RDW-15.8* Plt ___ ___ 06: 25AM BLOOD WBC-8.3 RBC-3.17* Hgb-8.4* Hct-27.5* MCV-87 MCH-26.6* MCHC-30.7* RDW-15.6* Plt ___ ___ 05: 00PM BLOOD WBC-9.1 RBC-3.34* Hgb-9.0* Hct-29.2* MCV-87 MCH-27.0 MCHC-30.9* RDW-14.6 Plt ___ ___ 06: 15AM BLOOD Neuts-64.4 ___ Monos-8.5 Eos-1.6 Baso-0.4 ___ 05: 35AM BLOOD Neuts-58.8 ___ Monos-7.4 Eos-3.3 Baso-0.5 ___ 06: 15AM BLOOD Neuts-67.0 ___ Monos-6.0 Eos-2.7 Baso-0.6 ___ 06: 20AM BLOOD Neuts-47* Bands-6* ___ Monos-11 Eos-6* Baso-0 Atyps-1* Metas-2* Myelos-0 ___ 06: 30AM BLOOD Neuts-71.7* ___ Monos-6.9 Eos-2.8 Baso-0.6 ___ 06: 15AM BLOOD Neuts-72.5* ___ Monos-4.7 Eos-2.2 Baso-0.5 ___ 01: 00AM BLOOD Neuts-74.9* ___ Monos-4.2 Eos-0.5 Baso-0.4 ___ 06: 15AM BLOOD Glucose-115* UreaN-14 Creat-0.9 Na-140 K-4.1 Cl-104 HCO3-26 AnGap-14 ___ 05: 35AM BLOOD Glucose-152* UreaN-13 Creat-0.8 Na-138 K-4.0 Cl-102 HCO3-29 AnGap-11 ___ 05: 55AM BLOOD Glucose-85 UreaN-8 Creat-0.8 Na-138 K-4.4 Cl-103 HCO3-28 AnGap-11 ___ 06: 10AM BLOOD Glucose-100 UreaN-8 Creat-0.7 Na-139 K-4.2 Cl-102 HCO3-30 AnGap-11 ___ 06: 10AM BLOOD Glucose-110* UreaN-6 Creat-0.7 Na-140 K-3.4 Cl-102 HCO3-27 AnGap-14 ___ 06: 15AM BLOOD Glucose-109* UreaN-10 Creat-0.8 Na-139 K-3.8 Cl-105 HCO3-26 AnGap-12 ___ 06: 25AM BLOOD Glucose-275* UreaN-13 Creat-0.9 Na-141 K-4.0 Cl-102 HCO3-29 AnGap-14 ___ 05: 00PM BLOOD Glucose-228* UreaN-13 Creat-0.8 Na-141 K-4.0 Cl-106 HCO3-24 AnGap-15 ___ 06: 15AM BLOOD Calcium-9.4 Phos-3.5 Mg-1.7 ___ 05: 35AM BLOOD Calcium-8.8 Phos-3.4 Mg-1.7 ___ 05: 42AM BLOOD Calcium-8.8 Phos-3.3 Mg-1.8 ___ 06: 15AM BLOOD Calcium-8.5 Phos-3.4 Mg-1.8 ___ 06: 30AM BLOOD Calcium-8.0* Phos-2.5* Mg-1.7 ___ 06: 30AM BLOOD Calcium-7.8* Phos-2.0* Mg-1.9 ___ 06: 15AM BLOOD Calcium-7.7* Phos-1.7* Mg-2.0 ___ 08: 20AM BLOOD Calcium-8.0* Phos-2.2* Mg-2.2 ___ 06: 25AM BLOOD Calcium-8.0* Phos-3.4 Mg-2.0 ___ 05: 00PM BLOOD Calcium-7.8* Phos-3.6 Mg-1.4* ___ 01: 44PM BLOOD Glucose-169* Lactate-3.0* Na-140 K-3.1* Cl-104 calHCO___-28 <MEDICATIONS ON ADMISSION> The Preadmission Medication list is accurate and complete. 1. Atenolol 50 mg PO DAILY 2. Amlodipine 2.5 mg PO DAILY 3. Furosemide 60 mg PO DAILY 4. Aspirin 81 mg PO DAILY 5. valsartan-hydrochlorothiazide 160-12.5 mg oral daily 6. MetFORMIN (Glucophage) 500 mg PO BID 7. HumaLOG Mix ___ KwikPen (insulin lispro protam-lispro) 100 unit/mL (75-25) subcutaneous BID hyperglycemia <DISCHARGE MEDICATIONS> 1. Amlodipine 2.5 mg PO DAILY 2. Atenolol 50 mg PO DAILY 3. Furosemide 60 mg PO DAILY 4. Aspirin 81 mg PO DAILY 5. valsartan-hydrochlorothiazide 160-12.5 mg oral daily 6. Ibuprofen 400 mg PO Q8H: PRN pain RX *ibuprofen 400 mg 1 tablet(s) by mouth every eight (8) hours Disp #*60 Tablet Refills: *0 7. OxycoDONE (Immediate Release) ___ mg PO Q4H: PRN pain Do not drive while on oxycodone RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours Disp #*50 Tablet Refills: *0 8. Acetaminophen 650 mg PO Q6H Do not exceed 4000mg acetaminophen/tylenol in 24 hrs RX *acetaminophen 650 mg 1 tablet(s) by mouth every six (6) hours Disp #*60 Tablet Refills: *0 9. Psyllium Wafer 1 WAF PO BID RX *psyllium [Metamucil] 1.7 g 1 wafer(s) by mouth twice a day Disp #*2 Wafer Refills: *2 10. Metoclopramide 5 mg PO TID Please take 20 minutes prior to meals. RX *metoclopramide HCl [Reglan] 5 mg 1 tablet(s) by mouth three times a day Disp #*30 Tablet Refills: *2 11. Humalog ___ 26 Units Breakfast Humalog ___ 26 Units Dinner Insulin SC Sliding Scale using HUM Insulin RX *insulin lispro protam-lispro [Humalog Mix ___ KwikPen] 100 unit/mL (75-25) 26 units subcutaneous 26 Units before BKFT; 26 Units before DINR; Disp #*20 Syringe Refills: *2 RX *insulin lispro [Humalog KwikPen] 100 unit/mL ___ units subcutaneous QID per sliding scale Disp #*1 Syringe Refills: *2 12. LOPERamide 2 mg PO BID: PRN high ostomy output may take if ostomy output > 1L in 24 hrs RX *loperamide [Anti-Diarrhea] 2 mg 1 tablet(s) by mouth twice a day Disp #*30 Tablet Refills: *1 <DISCHARGE DISPOSITION> Extended Care Facility: ___ <DISCHARGE DIAGNOSIS> endometrial carcinoma right ureteral transection with neoureterocystotomy diverting loop ileostomy rectosigmoid resection <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Dear Ms. ___, . You were admitted to the gynecologic oncology service after undergoing the procedures listed below. You have recovered well after your operation, and the team feels that you are safe to be discharged home. Please follow these instructions: . Abdominal instructions: * Take your medications as prescribed. * Do not drive while taking narcotics. * Do not combine narcotic and sedative medications or alcohol. * Do not take more than 4000mg acetaminophen (APAP) in 24 hrs. * No strenuous activity until your post-op appointment. * Nothing in the vagina (no tampons, no douching, no sex) for 12 weeks. * No heavy lifting of objects >10 lbs for 6 weeks. * You may eat a regular diet. * It is safe to walk up stairs. . Incision care: * You may shower and allow soapy water to run over incision; no scrubbing of incision. No bath tubs for 6 weeks. * You should remove your port site dressings ___ days after your surgery. If you have steri-strips, leave them on. If they are still on after ___ days from surgery, you may remove them. * If you have staples, they will be removed at your follow-up visit. . Ostomy Care: - Please follow ostomy care instructions provided, you will have ostomy care with visiting nursing service. . 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 * increased output from the ostomy * onset of any concerning symptoms
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Ms. ___ was admitted to the gynecology oncology service after undergoing total laparoscopic hysterectomy, converted to exploratory laparotomy, completion of abdominal hysterectomy, bilateral salpingo-oophorectomy, with repair of a right ureteral transection with right neoureterocystotomy, placement of right ureteral stent, rectosigmoid resection with protective diverting loop ileostomy. Please see the operative report for full details. Her post-operative course is detailed as follows. Immediately postoperatively, her pain was controlled with Dilaudid PCA/IV acetaminophen. She was transitioned to oral Percocet and ibuprofen when tolerating PO intake. She was given 24 hours of prophylactic Kefzol and Flagyl post-operatively. She had a fever to 101.8F on post operative day 2 with unremarkable CXR and negative blood, urine and abdominal drain cultures. She was started on empiric levofloxacin and Flagyl. She was transfused with 2 units packed RBC on post-operative day 2 for blood loss anemia with appropriate rise in hematocrit. She had a low grade temperature post-transfusion that resolved with Tylenol. She was transitioned to IV cefepime and Flagyl on post-operative day 3 for broader coverage. Her antibiotics were transitioned to PO ciprofloxacin and Flagyl on POD 14. She completed her course of antibiotics upon discharge. On post-operative day 4, increased serous drainage was noted from her midline incision. The incision was explored with cultures sent and the wound packed with BID dressing changes. Wound cultures were negative and she remained afebrile during the rest of her hospital stay. A wound vacuum was placed on post operatived day 8 and her staples were removed on post operative day 12. Her wound vacuum was replaced with wet to dry dressings for discharge to rehab. She continued to have a persistent leukocytosis and a CT abd/pelvis on post-operative day 6 showed unorganized anterior abdominal and pelvic fluid collection. She was continued on her antibiotic regiment. ___ was consulted for possible drainage on post operative day 7. Given unorganized collection and proximity of bowel to the fluid collection, decision was made to re-evaluate the collection with repeat CT on post-operative day 11. Repeat CT showed minimal interval decrease in size of unorganized collection and ___ drainage was not recommended and her leukocytosis resolved prior to discharge. Her diet was advanced slowly with episode of nausea and distension on post operative day 5. She was placed on bowel rest and then slowly advanced to a regular diet. She had postprandial nonbloody, nonbilious emesis on POD 14 likely secondary to diabetic gastroparesis which resolved with pre-meal Reglan. Her Foley was left in place for 9 days given her neoureterocystotomy. She produced adequate urine output during her hospital stay. A cystogram was preformed on post operative day 9. The Foley was removed and she voided spontaneously. Her hypertension was controlled on her home medications of atenolol, amlodipine, valsartan, HCTZ and lasix. She had elevated blood glucose levels post-operatively that was followed by ___ and controlled with sliding scale insulin and Lantus. She was transitioned to Humalog 75/25, with insulin sliding scale and metformin BID once tolerating a regular diet. Her metformin was stopped ___ due to nausea. Her blood glucose was controlled on discharged with Humalog ___ 26 U at breakfast and 26 U at dinner, with insulin sliding scale. She may be transitioned back to her home regiment in rehab. She received physical therapy consult and wound ostomy nursing consult during her stay and will be discharged home with short term rehab for ostomy care. By post-operative day 15, she was tolerating a regular diet, voiding spontaneously, ambulating with assistance, 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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10938653-DS-19
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> LLQ pain <MAJOR SURGICAL OR INVASIVE PROCEDURE> LAPAROSCOPIC BILATERAL OVARIAN CYSTECTOMIES <HISTORY OF PRESENT ILLNESS> ___ yo G3P3 who presents with 2 days of LLQ pain. Pain has been constant with episodes of stronger pain intermittently. Not worse with position change, or walking, has almost felt nausea but has been eating regular meals. Last ate at 1330 Known hx of ovarian dermoids. No vaginal bleeding. Was sent for an US today with 8-10 cm bilateral cystic dermoids with possible hemorrhage within the left cyst. <PAST MEDICAL HISTORY> POB/gyn hx SVD x3, vasectomy for contraception. regular monthly menses lmp ___ last pelvic US ___ with 2 and 3cm dermoids bilaterally pmh: chronic sinusitis psh: LSC cystectomy for dermoid, sinus surgery x 2 <SOCIAL HISTORY> ___ <FAMILY HISTORY> noncontributory <PHYSICAL EXAM> Exam on admission: HR 60 gen: well appearing abd soft, nt, nd, no rebound or guarding pelvic: Right adnexal mass, nontender, uterus anteverted, mild LLQ tenderness on exam. ext NT Exam on discharge: Vitals: stable and within normal limits Gen: no acute distress; alert and oriented to person, place, and date CV: regular rate and rhythm; no murmurs, rubs, or gallops Resp: no acute respiratory distress, clear to auscultation bilaterally Abd: soft, appropriately tender, no rebound/guarding; incision clean, dry, intact Ext: no tenderness to palpation <PERTINENT RESULTS> ___ 09: 45PM HCT-36.9 ___ 04: 20PM WBC-9.4 RBC-4.67 HGB-13.3 HCT-41.6 MCV-89 MCH-28.5 MCHC-32.0 RDW-13.3 RDWSD-43.5 ___ 04: 20PM PLT COUNT-250 <DISCHARGE INSTRUCTIONS> Dear Ms. ___, You were admitted to the gynecology service for pain management and surgery (laparoscopic bilateral ovarian cystectomy) for your dermoid cysts. 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. 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 for pain management and observation in the setting of intermittent LLQ pain with US findings of bilateral dermoid cysts concerning for intermittent torsion. She continued to have intermittent pain and was taken to the OR for a laparoscopic bilateral ovarian cystectomy. Please see the operative report for full details. Her post-operative course was uncomplicated. Immediately post-op, her pain was controlled with oxycodone, Tylenol, and ibuprofen. She was tolerating a regular diet, voiding spontaneously, ambulating independently, and pain was controlled with oral medications. She was then discharged home in stable condition with outpatient follow-up scheduled. Discharge Medications: 1. Acetaminophen 1000 mg PO Q6H:PRN Pain - Mild/Fever RX *acetaminophen 500 mg 2 tablet(s) by mouth every six (6) hours Disp #*60 Tablet Refills:*0 2. Ibuprofen 600 mg PO Q6H:PRN Pain - Mild RX *ibuprofen 600 mg 1 tablet(s) by mouth every six (6) hours Disp #*60 Tablet Refills:*0 3. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain - Severe RX *oxycodone 5 mg 1 tablet(s) by mouth every four (4) hours Disp #*15 Tablet Refills:*0 Discharge Disposition: Home Discharge Diagnosis: Bilateral dermoid cysts, hemorrhagic cyst Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___
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10940509-DS-25
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Efavirenz / Cymbalta <ATTENDING> ___ <CHIEF COMPLAINT> pelvic organ prolapse, stress urinary incontinence <MAJOR SURGICAL OR INVASIVE PROCEDURE> total vaginal hysterectomy, bilateral salpingo-oophorectomy, vault suspension, anterior repair, suburethral sling, cystoscopy <HISTORY OF PRESENT ILLNESS> Initial evaluation: ___ Mrs. ___ is a ___ gravida 8 para 5 who presents today in the office for consultation requested by ___, NP regarding vaginal prolapse. She is complaining of pelvic organ prolapse that has been present for the past ___ years but admits that over the past 12 month she has been have had exteriorized prolapse that is causing her some anxiety. She denies any change in her urinary habits. She voids ___ times per day in ___ times at night. She admits to occasional urgency incontinence. She drinks 1 cup of tea per day and denies any consumption of caffeine or artificial sweeteners. She had one UTI a year ago. Mrs. ___ denies any issues with constipation. She is not currently sexually active and does not experience any dyspareunia. She admits to vaginal dryness. Cataracts She is otherwise without any other significant complaints. Update: ___ Mrs. ___ returns today accompanied by her daughter. She states that her prolapse has worsened and is affecting her ability to have a bowel movement and to sit. She often has significant discomfort and has to reduce it manually to have a bowel movement or to void. She denies any bleeding, no dysuria no fever no chills. She is otherwise without any other significant complaints. <PAST MEDICAL HISTORY> PMH: hepatitis A, HIV, HLD, HTN, osteoporosis, thalassemia trait PSH: BTL, shoulder surgery, ? cholecystectomy, cataract surgery ObGyn: G8P5 (SVDx5), post menopausal <SOCIAL HISTORY> ___ <FAMILY HISTORY> non contributory <PHYSICAL EXAM> Discharge physical exam Vitals: VSS Gen: NAD, A&O x 3 CV: RRR Resp: no acute respiratory distress Abd: soft, appropriately tender, no rebound/guarding Ext: no TTP <MEDICATIONS ON ADMISSION> The Preadmission Medication list is accurate and complete. 1. Atorvastatin 40 mg PO QPM 2. Chlorthalidone 25 mg PO DAILY 3. LaMIVudine-Zidovudine (Combivir) 1 TAB PO BID 4. Lisinopril 40 mg PO DAILY 5. Raltegravir 400 mg PO BID 6. Aspirin 81 mg PO DAILY <DISCHARGE MEDICATIONS> 1. Acetaminophen 650 mg PO TID RX *acetaminophen 650 mg 1 tablet(s) by mouth every 8 hours Disp #*50 Tablet Refills: *1 2. Docusate Sodium 100 mg PO BID RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice daily Disp #*60 Capsule Refills: *1 3. Ibuprofen 400-600 mg PO Q8H: PRN Pain - Moderate Reason for PRN duplicate override: Alternating agents for similar severity take with food. RX *ibuprofen 200 mg ___ tablet(s) by mouth every 8 hours Disp #*50 Tablet Refills: *1 4. TraMADol ___ mg PO Q6H: PRN pain do not drive or drink alcohol while taking this medication. RX *tramadol 50 mg 0.5 (One half) tablet(s) by mouth every 6 hours Disp #*40 Tablet Refills: *0 5. walker miscellaneous DAILY RX *walker daily Disp #*1 Each Refills: *0 6. Aspirin 81 mg PO DAILY 7. Atorvastatin 40 mg PO QPM 8. Chlorthalidone 25 mg PO DAILY 9. LaMIVudine-Zidovudine (Combivir) 1 TAB PO BID 10. Lisinopril 40 mg PO DAILY 11. Raltegravir 400 mg PO BID <DISCHARGE DISPOSITION> Home With Service Facility: ___ <DISCHARGE DIAGNOSIS> stress urinary incontinence, 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. * Nothing in the vagina (no tampons, no douching, no sex) for 3 months. * No heavy lifting of objects >10 lbs for 6 weeks. * You may eat a regular diet. * You may walk up and down stairs. Incision care: * You may shower and allow soapy water to run over incision; no scrubbing of incision. No tub baths for 6 weeks. Call your doctor for: * fever > 100.4F * severe abdominal pain * difficulty urinating * vaginal bleeding requiring >1 pad/hr * abnormal vaginal discharge * redness or drainage from incision * nausea/vomiting where you are unable to keep down fluids/food or your medication 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 vaginal hysterectomy, bilateral salpingo-oophorectomy, vault suspension, anterior repair, suburethral sling, and cystoscopy for stress urinary incontinence and 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 toradol and hydromorphone. 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, ibuprofen, and tramadol. By post-operative day 1, she was tolerating a regular diet, voiding spontaneously, ambulating independently, and pain was controlled with oral medications. She was evaluated by physcial therapy who determined that she required a walker and home physical therapy. Case management also evaluated the patient and determined a need for skilled nursing/home health aid. She was then discharged home in stable condition with outpatient follow-up scheduled.
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10940509-DS-26
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Efavirenz / Cymbalta <ATTENDING> ___ <CHIEF COMPLAINT> fevers, cough, abdominal pain <MAJOR SURGICAL OR INVASIVE PROCEDURE> None <HISTORY OF PRESENT ILLNESS> ___ POD2 from ___, BSO, vault suspension, anterior repair, sub-urethral sling, and cystoscopy c/b bladder perforation who presents to the ED with fevers, suprapubic pain, dysuria, and cough. Patient reports pain started earlier today with associated dysuria, increased urinary frequency, and straining to void. No hematuria. She had associated nausea at the time with fevers and chills that progressed later in the day. She was taking acetaminophen at home for pain with no improvement. She denies any dizziness, chest pain, or shortness or breath. She has mild vaginal spotting, no abnormal discharge. ROS: all systems reviewed and negative unless mentioned above <PAST MEDICAL HISTORY> PMH: - hepatitis A - HIV - HLD - HTN - osteoporosis - thalassemia trait PSH: - BTL - shoulder surgery - ? cholecystectomy - cataract surgery - TVH, BSO, AP repair, rectopubic mid urethral sling, cysto ObGyn: G8P5 (SVDx5), post menopausal All: - Cymbalta - Efavirenz <SOCIAL HISTORY> ___ <FAMILY HISTORY> not contributory <PHYSICAL EXAM> Vitals: 98.0, BP 150 / 65, HR 73, RR 18, SpO2 97% RA General: alert and oriented x3, no acute distress Cardiovascular: regular rate and rhythm, normal s1 and s2, no murmurs, rubs, or gallops Pulmonary: normal work of breathing, left lung field is cta, right lung has fine crackles at base to mid-lung field (improved since yesterday) Abdominal: normal active bowel sounds, soft, non-distended, mildly tender to palpation in the suprapubic area, no masses palpated Extremities: warm and well perfused, no calf tenderness, no edema, pneumoboots on <PERTINENT RESULTS> ___ 08: 20AM WBC-8.5 RBC-2.99* HGB-9.6* HCT-28.6* MCV-96 MCH-32.1* MCHC-33.6 RDW-12.5 RDWSD-43.4 ___ 08: 20AM NEUTS-77* BANDS-0 LYMPHS-16* MONOS-5 EOS-2 BASOS-0 ___ MYELOS-0 AbsNeut-6.55* AbsLymp-1.36 AbsMono-0.43 AbsEos-0.17 AbsBaso-0.00* ___ 09: 25PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.5 LEUK-NEG ___ 07: 54PM WBC-6.5 LYMPH-18* ABS LYMPH-1170 CD3-75 ABS CD3-876 CD4-35 ABS CD4-413 CD8-39 ABS CD8-459 CD4/CD8-0.90 <MEDICATIONS ON ADMISSION> Vitamin D 1000 UNIT PO DAILY Acetaminophen 650 mg PO Q4H Aspirin 81 mg PO DAILY Atorvastatin 40 mg PO QPM Chlorthalidone 25 mg PO DAILY Clobetasol Propionate 0.05% Ointment 1 Appl TP BID apply to bumps twice a day Docusate Sodium 100 mg PO BID Ibuprofen 400 mg PO Q6H: PRN Pain - Mild Take with food to reduce nausea/ upset stomach. RX *ibuprofen 200 mg 2 tablet(s) by mouth every 6 hours Disp #*60 Tablet Refills: *1 LaMIVudine-Zidovudine (Combivir) 1 TAB PO BID Lisinopril 40 mg PO DAILY Mirtazapine 7.5 mg PO QHS Omeprazole 20 mg PO IN THE MORNING AND AFTERNOON Raltegravir 400 mg PO BID TraMADol ___ mg PO Q6H: PRN pain <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. Polyethylene Glycol 17 g PO DAILY RX *polyethylene glycol 3350 17 gram 1 powder(s) by mouth daily Disp #*7 Packet Refills: *1 3. Senna 17.2 mg PO HS RX *sennosides 8.6 mg 2 tablets by mouth at night Disp #*30 Tablet Refills: *1 4. Acetaminophen 650 mg PO Q4H 5. Aspirin 81 mg PO DAILY 6. Atorvastatin 40 mg PO QPM 7. Chlorthalidone 25 mg PO DAILY 8. Clobetasol Propionate 0.05% Ointment 1 Appl TP BID apply to bumps twice a day 9. Docusate Sodium 100 mg PO BID 10. Ibuprofen 400 mg PO Q6H: PRN Pain - Mild Take with food to reduce nausea/ upset stomach. RX *ibuprofen 200 mg 2 tablet(s) by mouth every 6 hours Disp #*60 Tablet Refills: *1 11. LaMIVudine-Zidovudine (Combivir) 1 TAB PO BID 12. Lisinopril 40 mg PO DAILY 13. Mirtazapine 7.5 mg PO QHS 14. Omeprazole 20 mg PO IN THE MORNING AND AFTERNOON 15. Raltegravir 400 mg PO BID 16. TraMADol ___ mg PO Q6H: PRN pain 17. Vitamin D 1000 UNIT PO DAILY <DISCHARGE DISPOSITION> Home With Service Facility: ___ <DISCHARGE DIAGNOSIS> Aspiration pneumonia Post-operative from total vaginal hysterectomy, bilateral salpingo-oopherectomy, vault suspension, anterior repair, sub-urethral sling , cystoscopy on ___ <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 hospital two days after your surgery because you had a fever, trouble urinating, abdominal pain, and cough. We found that you had developed pneumonia, or infection of your lung. We kept you in the hospital in order to start you on IV antibiotics. Once you were feeling better, eating and drinking on your own, we changed your antibiotics to one you take by mouth. You will continue taking these at home. TAKE ALL OF YOUR ANTIBIOTICS. DO NOT STOP TAKING THEM UNTIL THE BOTTLE RUNS OUT, even if you start to feel better. We found that you do NOT have a urinary tract infection and were urinating well on your own, so you do not need a urinary catheter. You may continue to have lower abdominal pain for a few days-weeks after surgery. It should improve gradually. You have prescriptions to take for pain from you last admission. Please take those when you are in pain. You may take the Tylenol and ibuprofen regularly, every six hours. If you still have pain, you may take the tramadol (up to every 6 hours). You should take a stool softener (Colace) every day, ___ times per day. If you are constipated you may also take a laxative such as senna or miralax. If you are still having difficulties having a bowel movement, please call the office. 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.
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Ms. ___ is a ___ year old woman who presented on POD 2 from a ___, BSO, vault suspension, anterior repair, sub-urethral sling, cystoscopy for pelvic organ prolapse and stress urinary incontinence with fevers, cough, and abdominal pain. Her initial exam was notable for a T max of ___ F, tachycardia to 115, ronchi over the right lower lung field, and tenderness to palpation in the suprpubic and right lower quadrant without rebound or guarding. Her WBC and lactate were within normal limits, and a urinalysis was also normal. Still, given her immunocompromised state, urine and blood cultures were ordered (urine = no growth; blood = pending). A chest X Ray showed a right middle lobe consolidation, which was confirmed on CT. CT abdomen and pelvis also demonstrated a 2.8 x 3.8 phlegmon without a drainable fluid collection. The foley that was place in the ED out of concern for retention was removed on hospital day 2 after she passed a trial of void ___ cc in, 150 cc out). Based on these findings she was diagnosed with an aspiration pneumonia with low concern for intrabdominal/post-surgical infection. She was started on Ceftriaxone/cipro/flagyl on ___ and, as her condition improved, narrowed to unasyn on ___ and then augmentin on ___ once she was tolerating oral food and medication. She is prescribed a seven day course, last day being ___. Her abdominal pain was attributed to post-operative pain. Of note, Ms. ___ experience poor pain control during her last admission. She rarely asks for PRN medications. Once she was discharged on ___, her pain medication prescriptions were not filled for nearly 24 hours. During this hospital stay, she received scheduled acetaminophen and ibuprofen with PRN tramadol ___ mg PO for breakthrough. Pain control was good and she remained comfortable. Still, the antibiotic regimen she received was intended to cover possible intra-abdominal infection if present. There were no changes in the management of her chronic conditions, and she remained on her home regimens for HIV, hypertension, hyperlipidemia.
| 1,932
| 464
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10940920-DS-20
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Patient recorded as having No Known Allergies to Drugs <ATTENDING> ___ <CHIEF COMPLAINT> - admission for induction of labor <MAJOR SURGICAL OR INVASIVE PROCEDURE> - primary low transverse cesarean section <HISTORY OF PRESENT ILLNESS> ___ yo G1P0 @ 37+6 with h/o elevated blood pressures and freq HA's during this pregnancy. Was seen in the office today and again had elevated BP, and thus was sent for induction of labor. Has had multiple pre-eclampsia evaluations including antepartum admission. Her labs have always been wnl including a 24h urine protein of 108. Today her HA is ___, "mild", frontal, last took tylenol at 7: 30am with some improvement. No epigastric pain, visual changes. +AFM, no LOF, no VB. <PAST MEDICAL HISTORY> PNC: ___: ___ by LMP consistent w/7+4 wk u/s FFS: nl anatomy, S=D, 5 cm retroplacental fibroid on L ERA: DS Risk 1 in 950, RiskTri 18: 1 in ___ NT: 1.3mm, declined amnio. Labs: O-, Ab-, RI, RPRNR, GC-, CT-, HIV-, TFTs nl CF-, GLT 88, GBS negative Rhogam received ___ EFW 2332 (60%)at 33w1d---> ___ EFW 55%tile (3058g) OBSTETRIC HISTORY G1 GYNECOLOGIC HISTORY LMP: ___. Cycle length 28 days. hx of abnl PAP ___ yrs ago, normal follow up one episode of genital HSV ___ yrs ago (for acyclovir) uterine polyp removal ___ years ago PAST MEDICAL HISTORY anxiety, depression PAST SURGICAL HISTORY uterine polyp removal wisdom tooth extraction no anesthetic complications basal cell removed from face <SOCIAL HISTORY> ___ <FAMILY HISTORY> father HTN, DM, MI at ___ yrs old mother heart disease <PHYSICAL EXAM> (on admission) VITALS: HR 86, BP 155/91 GENERAL: NAD ABDOMEN: gravid, NT, EFW 7#10oz SSE: no lesions SVE: cl/50%/-2, soft FHT: 145, moderate variability, +accels, - decels TOCO: irritable <PERTINENT RESULTS> ___ WBC-12.2 RBC-4.16 Hgb-12.6 Hct-37.5 MCV-90 Plt-347 ___ WBC-13.2 RBC-3.95 Hgb-12.3 Hct-35.9 Plt-322 ___ WBC-13.1 RBC-4.34 Hgb-13.3 Hct-38.9 MCV-90 Plt-310 ___ Creat-0.6 ALT-10 UricAcd-4.5 ___ Creat-0.5 ALT-11 UricAcd-4.5 ___ Creat-0.6 ALT-10 UricAcd-4.9 . ___ URINE Hours-RANDOM Creat-170 TotProt-23 Pr/Cr-0.1 . URINE CULTURE (Final ___: MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION <MEDICATIONS ON ADMISSION> - nifedipine CR 30 daily - prenatal vitamins <DISCHARGE MEDICATIONS> 1. Oxycodone-Acetaminophen ___ mg Tablet Sig: ___ Tablets PO every ___ hours as needed for Pain. Disp: 40 Tablet(s) Refills: 0 2. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for Pain. Disp: 40 Tablet(s) Refills: 0 3. Nifedipine 30 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO BID (2 times a day). Disp: 60 Tablet Sustained Release(s) Refills: 2 <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> - Cesarean delivery - gestational hypertension <DISCHARGE CONDITION> - good <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> - routine postpartum instructions given
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___ yo G1P0 admitted at 37+6 weeks for induction of labor due to worsening gestational hypertension. . Ms. ___ was admitted for induction. Her initial blood pressure was 155/91. She reported a mild headache; otherwise, she had no signs or symptoms of superimposed preeclampsia. Fetal testing was reassuring. She had an unfavorable cervix and received four doses of cytotec for cervical ripening. Unfortunately, her cervix did not respond and she was sent to the antepartum floor for rest and further observation. Her blood pressures and labs were stable. Fetal testing was reassuring. She remained stable until 38+6 weeks when she reported an unremitting headache and her blood pressures were 150s/90s. She was brought up to Labor and Delivery for a second attempt at induction, and progressed to the ___ stage of labor. However, after 3 hours of pushing, minimal progress was made and she underwent Cesarean delivery due to arrest of descent. Please see the operative report in OMR for full details. . Postpartum her nifedipine was titrated up from 30mg CR once daily to twice daily, and her postpartum course was otherwise unremarkable. Her blood pressures were well-controlled on discharge home.
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| 270
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10941676-DS-15
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> uterine carcinosarcoma <MAJOR SURGICAL OR INVASIVE PROCEDURE> robot-assisted total laparoscopic hysterectomy, bilateral salpingo-oophorectomy, pelvic lymph node dissection, para-aortic lymph node dissection, omental biopsy, cystoscopy <HISTORY OF PRESENT ILLNESS> ___ yo female referred to ___ clinic for evaluation of uterine carcinosarcoma, diagnosed on endometrial biopsy ___. Patient initially presented to Dr. ___ on ___ after an episode of post menopausal bleeding on ___. She had been postmenopausal for ___ years and reported that the bleeding was enough that she had to wear a pantiliner, but other times was noticeable only when she wiped. She underwent endometrial biopsy on ___, which showed endometrial carcinosarcoma (malignant mixed mullerian tumor) concerning for a high grade malignancy. Today, she reports that she continues to bleed, soaking less than one pad per day. She has also noticed some abdominal cramping (typically right lower quadrant). Reports decreased appetite in the setting of stress, but no large amount of weight loss. She is complaining of some constipation today, but otherwise feels well. She does note that she has had several months of watery vaginal discharge. She is currently being treated for a urinary tract infection (last dose of antibiotics tomorrow). She otherwise feels well today. Of note, she has a history of fibroids and used to have very heavy menses. She had a pelvic U/S in ___ which showed multiple fibroids unchanged from ___, poorly visualized endometrium due to fibroids but apparently no thicker than 2mm where noted. She has not had a repeat ultrasound. She denies recent weight changes, chest pain, shortness of breath, nausea, and vomiting. ROS: Otherwise 10 point review of systems is negative except as above. <PAST MEDICAL HISTORY> PMH: - Goiter, nontoxic, multinodular - Esophageal reflux - Colonic adenoma - Sleep apnea - Obesity - Osteopenia - Vitamin D deficiency - Cervical high risk HPV (human papillomavirus) test positive - Right ovarian cyst - Denies history of heart or respiratory disease, hypertension, thromboembolic disease, cancer history. PSH: - Removal of metal plate in arm (___) (___) - Abdominal myomectomy (___) (___) - C/S x2 (___) (___) - Fracture of left arm (___) (___) HCM: Last mammogram: ___ Last colonoscopy: ___ years ago" Last bone density scan: ___ POBHx: G2P2 (2 C/S) PGYNHx: LMP: ___ Fibroids: yes Cysts: yes STIs: denies Contraception: n/a ___: unknown Last pap: ___ (normal, HPV negative) History abnormal pap: ___, subsequent normal <SOCIAL HISTORY> ___ <FAMILY HISTORY> FamHx: Denies history of gyn or colon cancer, bleeding or clotting disorder. Significant for hypertension (paternal aunts). <PHYSICAL EXAM> On day of discharge: Afebrile, vitals stable No acute distress CV: regular rate and rhythm Pulm: clear to auscultation bilaterally Abd: soft, appropriately tender, nondistended, incision clean/dry/intact, no rebound/guarding ___: nontender, nonedematous <PERTINENT RESULTS> ___ 09: 20AM BLOOD WBC-15.0* RBC-3.60* Hgb-11.5 Hct-34.3 MCV-95 MCH-31.9 MCHC-33.5 RDW-13.1 RDWSD-45.7 Plt ___ ___ 09: 50PM BLOOD WBC-15.4* RBC-3.58* Hgb-11.4 Hct-33.3* MCV-93 MCH-31.8 MCHC-34.2 RDW-13.2 RDWSD-44.9 Plt ___ ___ 06: 55AM BLOOD WBC-12.4* RBC-3.55* Hgb-11.3 Hct-33.2* MCV-94 MCH-31.8 MCHC-34.0 RDW-13.0 RDWSD-44.8 Plt ___ ___ 01: 06PM BLOOD WBC-16.4*# RBC-3.99 Hgb-12.8 Hct-37.2 MCV-93 MCH-32.1* MCHC-34.4 RDW-13.1 RDWSD-44.8 Plt ___ ___ 09: 20AM BLOOD Neuts-76.5* Lymphs-10.4* Monos-11.8 Eos-0.7* Baso-0.2 Im ___ AbsNeut-11.45* AbsLymp-1.56 AbsMono-1.77* AbsEos-0.11 AbsBaso-0.03 ___ 09: 50PM BLOOD Neuts-65.3 ___ Monos-11.7 Eos-0.5* Baso-0.3 Im ___ AbsNeut-10.05* AbsLymp-3.35 AbsMono-1.80* AbsEos-0.08 AbsBaso-0.04 ___ 09: 20AM BLOOD Glucose-122* UreaN-8 Creat-0.4 Na-135 K-4.0 Cl-101 HCO3-26 AnGap-12 ___ 06: 55AM BLOOD Glucose-93 UreaN-9 Creat-0.4 Na-136 K-4.3 Cl-106 HCO3-25 AnGap-9 ___ 01: 06PM BLOOD Glucose-129* UreaN-15 Creat-0.4 Na-140 K-3.9 Cl-106 HCO3-23 AnGap-15 ___ 09: 20AM BLOOD Calcium-7.9* Phos-2.6* Mg-2.0 ___ 06: 55AM BLOOD Calcium-8.1* Phos-3.6 Mg-2.0 ___ 01: 06PM BLOOD Calcium-8.4 Phos-4.3 Mg-1.9 <MEDICATIONS ON ADMISSION> - RANITIDINE 300 MG BID - Lorazepam 0.5 - 1 mg PRN - Calcium 1000 mg daily <DISCHARGE MEDICATIONS> 1. Acetaminophen ___ mg PO Q6H: PRN Pain - Mild RX *acetaminophen 500 mg ___ tablet(s) by mouth every 6 hours Disp #*50 Tablet Refills: *1 2. Docusate Sodium 100 mg PO BID: PRN constipation RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice per day Disp #*60 Capsule Refills: *1 3. HYDROmorphone (Dilaudid) ___ mg PO Q4H: PRN Pain - Moderate Do not drink alcohol or drive. RX *hydromorphone [Dilaudid] 2 mg ___ tablet(s) by mouth every 4 hours Disp #*20 Tablet Refills: *0 4. Ibuprofen 600 mg PO Q6H: PRN Pain RX *ibuprofen 600 mg 1 tablet(s) by mouth every 6 hours Disp #*50 Tablet Refills: *1 5. LORazepam 0.5 mg PO Q8H: PRN anxiety RX *lorazepam [Ativan] 0.5 mg 0.5 (One half) mg by mouth three times daily Disp #*30 Tablet Refills: *1 6. Omeprazole 20 mg PO DAILY RX *omeprazole 20 mg 1 capsule(s) by mouth once daily Disp #*30 Capsule Refills: *2 7. Ondansetron ___ mg PO Q8H: PRN nausea RX *ondansetron HCl 4 mg ___ tablet(s) by mouth three times daily Disp #*30 Tablet Refills: *2 8. Artificial Tears ___ DROP BOTH EYES PRN irritation 9. Calcium Carbonate 500 mg PO QID: PRN heartburn 10. Ranitidine 300 mg PO BID <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. * 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. . Reflux: * Continue to take rantidine and tums, as well as omeprazole. . Nausea: * Take Zofran (ondansetron) three times daily as needed for nausea. . Anxiety: * Take Ativan as needed three times a day. . 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 robot-assisted total laparoscopic hysterectomy, bilateral-salpingo-oophorectomy, pelvic and para-aortic lymph node dissection, 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 IV dilaudid. Her diet was advanced without difficulty and she was transitioned to PO tylenol, ibuprofen, and oxycodone. On post-operative day #1, her urine output was adequate so her Foley catheter was removed and she voided spontaneously. On post operative day #1, patient developed a brief episode of epigastric discomfort, diaphoresis, and tachycardia (120's). EKG x 2 showed normal sinus rhythm. Cardiac enzymes and troponins were sent which were both negative. Her epigastric discomfort resolved with omeprazole and her tachycardia improved with a 500cc bolus. She also experienced significant anxiety with poor pain control. She was trialed on dilaudid, and was started on her home At___. She then had a recurrent episode of epigastric discomfort associated with nausea on post operative day #2. Repeat labs were stable, and she had another set of negative troponins, and another stable EKG. Her symptoms improved with Zofran and Ativan. 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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10942309-DS-16
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> fever <MAJOR SURGICAL OR INVASIVE PROCEDURE> steroids for fetal lung maturity repeat c-section of di-di twins IV antibiotics <HISTORY OF PRESENT ILLNESS> Ms ___ is a ___ yo G3P2 at 31wk0d with didi twins complicated by PPROM of twin B at 22 weeks presents with fever of 100.4 at home today. Patient recently seen in triage on ___ with fever to 100.4. She had negative work up and symptoms felt to be secondary to viral URI. Patient reports persitent cough and URI symptoms. Denies abdominal pain, foul smelling discharge, dysuria, frequency. Antepartum course is significant for an antepartum admission for 3 days, but bleeding stopped and was discharged. Noted at that time that fluid around baby B was low, diagnosed with normal to mild oligohydramnios. Speculum exam could not confirm rupture. Also noted to be severely anemic at hct 23.7. Was given IV iron therapy at the time. Over the next 8 weeks weekly ultrasounds showed fluid around baby B to be mild oligo, otherwise adequate fetal growth, doppler umbilical blood flow. She continued to leak some fliud and blood. Spec exams could not confirm rupture of membranes, but the dx of probable SROM was kept, along with marginal abruption. Steroids were given at 25 weeks. Another round of IV iron was given at 28 weeks. Patient was seen ___ for a fever and URI in OB triage. Fetal well being was documented, spec exam could not confirm ROM. Patient could not tolerate a Influenza swab. Her symptoms were presumed to be secondary to a URI. Patient remained afebrile until ___, with one episode of fever at home and also a larger gush of fluid. Patient also reported continual symptoms of an upper respiratory infection. Exam on ___ did confirm fluid in vaginal vault. BPP were ___ for baby A and baby B. Baby B had moderate oligohydramnios. Rescue steroids were given and patient was admitted to the antepartum service. <PAST MEDICAL HISTORY> POBHx: LTCS x2 for NRFHT (both) PGYNhx: infertility. denies known fibroids or abnl pap PMHx: eczema, depression, anxiety PSHx: LTCS x2 <SOCIAL HISTORY> ___ <FAMILY HISTORY> noncontributory <PHYSICAL EXAM> On the day of discharge: Gen: NAD, well-appearing CV: RRR Pulm: CTAB Abd: soft, fundus firm at umbilicus, appropriately tender to palpation, no rebound/guarding, + BS GU: minimal spotting on pad Ext: WWP non-tender <PERTINENT RESULTS> ___ 12: 20AM BLOOD WBC-11.2* RBC-3.55* Hgb-6.9* Hct-23.6* MCV-66* MCH-19.5* MCHC-29.3* RDW-21.2* Plt ___ ___ 12: 20AM BLOOD Neuts-90* Bands-0 Lymphs-5* Monos-2 Eos-0 Baso-0 ___ Myelos-3* NRBC-1* ___ 03: 15PM BLOOD WBC-9.6 RBC-4.01* Hgb-8.0* Hct-29.3* MCV-73*# MCH-20.0* MCHC-27.3* RDW-23.4* Plt ___ ___ 03: 15PM BLOOD Neuts-90.9* Lymphs-7.4* Monos-1.3* Eos-0.1 Baso-0.3 ___ 07: 10PM BLOOD WBC-9.3 RBC-3.21* Hgb-6.3* Hct-22.3* MCV-69* MCH-19.6* MCHC-28.2* RDW-25.3* Plt ___ ___ 07: 10PM BLOOD Neuts-84* Bands-11* Lymphs-2* Monos-1* Eos-0 Baso-0 ___ Metas-1* Myelos-1* NRBC-4* ___ 12: 18AM BLOOD WBC-17.3*# RBC-2.88* Hgb-5.7* Hct-20.8* MCV-72* MCH-19.9* MCHC-27.5* RDW-25.3* Plt ___ ___ 12: 18AM BLOOD Neuts-85* Bands-13* Lymphs-1* Monos-0 Eos-0 Baso-0 Atyps-1* ___ Myelos-0 ___ 09: 00AM BLOOD WBC-22.3* RBC-3.65*# Hgb-8.2*# Hct-27.7*# MCV-76* MCH-22.4*# MCHC-29.6* RDW-23.8* Plt ___ ___ 07: 10PM BLOOD Glucose-101* UreaN-4* Creat-0.4 Na-137 K-2.8* Cl-110* HCO3-20* AnGap-10 ___ 12: 18AM BLOOD Glucose-95 UreaN-3* Creat-0.5 Na-138 K-3.7 Cl-109* HCO3-23 AnGap-10 ___ 09: 00AM BLOOD Glucose-87 UreaN-5* Creat-0.6 Na-137 K-3.9 Cl-108 HCO3-21* AnGap-12 ___ 07: 10PM BLOOD Calcium-7.6* Phos-1.0*# Mg-1.3* ___ 12: 18AM BLOOD Calcium-7.4* Phos-1.9* Mg-1.2* ___ 09: 00AM BLOOD Calcium-7.9* Phos-2.9 Mg-1.4* ___ 07: 10PM BLOOD TSH-1.1 ___ 12: 20AM URINE Color-Yellow Appear-Clear Sp ___ ___ 12: 20AM URINE Blood-MOD Nitrite-NEG Protein-TR Glucose-NEG Ketone-10 Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-LG ___ 12: 20AM URINE RBC-8* WBC-86* Bacteri-FEW Yeast-NONE Epi-3 TransE-<1 ___ 12: 20AM URINE Mucous-RARE ___ 2: 43 am BLOOD CULTURE x2 Source: Venipuncture. Blood Culture, Routine (Final ___: NO GROWTH ___ 12: 20 am URINE Source: ___. URINE CULTURE (Final ___: ESCHERICHIA COLI. >100,000 ORGANISMS/ML.. PRESUMPTIVE IDENTIFICATION. Cefazolin interpretative criteria are based on a dosage regimen of 2g every 8h. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ESCHERICHIA COLI | AMPICILLIN------------ <=2 S AMPICILLIN/SULBACTAM-- <=2 S CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- <=16 S PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S <MEDICATIONS ON ADMISSION> 1. PNV 2. Iron 3. Tums 4. Colace <DISCHARGE MEDICATIONS> 1. Oxycodone-Acetaminophen (5mg-325mg) ___ TAB PO Q4H RX *oxycodone-acetaminophen 5 mg-325 mg 1 tablet(s) by mouth four times a day Disp #*45 Tablet Refills: *0 2. Ibuprofen 600 mg PO Q6H: PRN Pain RX *ibuprofen 600 mg 1 tablet(s) by mouth four times a day Disp #*45 Tablet Refills: *1 3. Breast Pump hospital grade, double electric pump disp 1 use as directed 4. Guaifenesin-CODEINE Phosphate ___ mL PO Q6H: PRN cough RX *codeine-guaifenesin 100 mg-10 mg/5 mL ___ ml by mouth three times a day Disp ___ Milliliter Refills: *0 <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> twins, premature labor premature rupture of membranes chorioamnionitis UTI previous c-section anemia, severe <DISCHARGE CONDITION> good <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> no heavy lifting, exercise, baths for 4 weeks
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Ms. ___ is a ___ G3P2 with IVF di-di twins with likely PPROM between 15 and 22 weeks and possible abruption admitted to the antepartum service on ___ for fever, confirmed rupture of membranes, and moderate oligohydramnios of baby B. Rescue steroids were given. Repeat BPP on ___ was ___ x 2. In the AM of ___ the patient went into spontaneous preterm labor, was brought to L&D and was found to be 4 cm dilated. She was counseled re diagnosis of likely developing chorioamnionitis secondary to prolonged rupture, WBC 11.2 with 90% neutrophils (elevated from 9.3 one week prior), and fever at home, though it was felt that fever could also be secondary to viral syndrome and she did not have other evidence of chorioamnionitis. Given evidence of labor and concern for chorioamnionitis, the decision was made to proceed with a repeat cesarean section, given her history of 2 prior cesarean sections and unfavorable twin presentation, breech and transverse. She underwent an uncomplicated repeat cesarean section with low transverse incision converted to J-shaped incision in modified T fashion at 31w2d gestation. EBL 800cc. Full details available in the operative note. She was started on IV antibiotics (Gentamicin, Clindamycin) for concern for chorioamnionitis. Post-operatively in the recovery unit, patient developed hypotension and tachycardia, meeting SIRS criteria. WBC increased to 17.3 then 22.3 (13% bands). Presumed source of sepsis was chorioamnionitis, however, urine culture sent ___ returned positive for +E coli infection, therefore sepsis secondary to urinary tract infection, or URI, or combination, were also considered as possible sources. In order to provide full antimicrobial coverage, Ampicillin was added to her antibiotic course. Hct fell to 20.8. She was transfused 2 units pRBCs, with appropriate increase in Hct to 27.7 post-transfusion. She received IV fluids and her electrolytes were repleted. Her vital signs gradually improved. Blood cultures drawn ___ were negative. She was transferred to the post-partum floor once clinically stable on ___. The remainder of her post-partum course was uncomplicated. She remained afebrile with normal vital signs. Her foley catheter was removed and she voided spontaneously. Her antibiotics were discontinued on ___. Her diet was advanced. Her pain was well controlled with oral pain medications. By post-partum day 4, she was clinically stable, tolerating a regular diet, voiding, ambulating, with pain well controlled with oral pain medications. She was discharged home in stable condition with outpatient follow-up scheduled.
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10943197-DS-10
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Percocet / butalbital <ATTENDING> ___. <CHIEF COMPLAINT> prolapse <MAJOR SURGICAL OR INVASIVE PROCEDURE> anterior and posterior colporrhaphy, tension free vaginal tape, cysto <HISTORY OF PRESENT ILLNESS> Ms. ___ is ___ year-old female who initially presented with complaints of a bulge protruding outside the vagina for the last 2 months. She noticed it more with heavy lifting and exercise. She also had urinary incontinence with vigorous exercise and running, but not with coughing or sneezing. She had urge incontinence on rare occasions only. Her daytime urinary frequency was every 2 hours with nocturia x 1. She had no difficulty starting or maintaining the urine stream. She had no recent history of UTI. She did not have fecal incontinence. She desired surgical management. She had pre-operative urodynamic testing which revealed incomplete bladder emptying <PAST MEDICAL HISTORY> OB HISTORY: Gravida 3, para 3, vaginal birth 3, stillborn 1. PMH: asthma, obesity PSH: tubal ligation <SOCIAL HISTORY> ___ <FAMILY HISTORY> Her sister had a vaginal reconstructive surgery with mesh. She has had multiple problems related to the surgery and has required excision of scar tissue and mesh. <PHYSICAL EXAM> Gen: NAD, comfortable, ambulating in hall CV: RRR Lungs: CTAB Abd: soft, non-tender, +BS, suprapubic incision clean and intact with dermabond in place GU: voiding spontaneously, minimal spotting on pad Ext: non-tender <MEDICATIONS ON ADMISSION> The Preadmission Medication list is accurate and complete. 1. Albuterol Inhaler 1 PUFF IH Q4H: PRN wheezing 2. Lorazepam 0.5 mg PO DAILY anxiety <DISCHARGE MEDICATIONS> 1. Albuterol Inhaler 1 PUFF IH Q4H: PRN wheezing 2. Hydrocodone-Acetaminophen (5mg-500mg) ___ TAB PO Q4H: PRN pain Rx given in office. 3. Lorazepam 0.5 mg PO DAILY anxiety RX *lorazepam [Ativan] 0.5 mg 0.5 (One half) mg by mouth at bedtime Disp #*5 Tablet Refills: *0 <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> vaginal prolapse <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 pleasure caring for you on the gynecology service. You have recovered well and the team now feels you are safe to discharge home. Please follow these instructions: General instructions: * Take your medications as prescribed. * Do not drive while taking narcotics. * Take a stool softener such as colace while taking narcotics to prevent constipation * Do not combine narcotic and sedative medications or alcohol * Do not take more than 4000mg acetaminophen (APAP) in 24 hrs * No strenuous activity until your post-op appointment * Nothing in the vagina (no tampons, no douching, no sex) for 6 weeks * No heavy lifting of objects >10 lbs for 6 weeks. * You may eat a regular diet Incision care: * You may shower and allow soapy water to run over incision; no scrubbing of incision. No bath tubs for 6 weeks. Call your doctor for: * fever > 100.4 * severe abdominal pain * difficulty urinating * vaginal bleeding requiring >1 pad/hr * abnormal vaginal discharge * redness or drainage from incision * nausea/vomiting where you are unable to keep down fluids/food or your medication To reach medical records to get the records from this hospitalization sent to your doctor at home, call ___.
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On ___, Ms. ___ was admitted to the gynecology service after undergoing an anterior colporrhaphy, posterior colporrhaphy. perineal repair, and suburethral sling. Please see the operative report for full details. Her post-operative course was uncomplicated. On post-operative day 1, her urine output was adequate so her foley was removed and she had a successful formal voiding trial. Her diet was advanced without difficulty and she was transitioned to oral pain medications. 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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10945510-DS-7
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> advanced cervical dilation <MAJOR SURGICAL OR INVASIVE PROCEDURE> vaginal delivery <HISTORY OF PRESENT ILLNESS> ___ yo G2P1 at ___ presents from ___ after being found to be dilated to 3 cm with BBOW on routine full fetal survey. Denies ctx, VB, LOF. Denies any trauma. Intercourse this morning. <PAST MEDICAL HISTORY> PNC: - ___ ___ by ultrasound - Labs B pos/Abs neg/Rub I/RPR NR/HBsAg neg/HIV neg - Screening: low risk ERA, ___, 46XY, sickle trait OBHx: G2P1 - G1: SVD at 36 wks, no complications - G2: current GynHx: - h/o HPV - h/o HSV - denies fibroids, Gyn surgery PMH: anemia, eczema, sickle trait, h/o depression PSH: wisdom teeth <SOCIAL HISTORY> ___ <FAMILY HISTORY> Noncontributory <PHYSICAL EXAM> VS: T 98.7 HR 83 BP 134/69 RR 18 Gen: A&O, comfortable CV: RRR PULM: CTAB Abd: soft, gravid, nontender Ext: no calf tenderness SSE: bulging membranes in the vagina, no visible cervix; exam performed by ___ Fellow ___ on discharge: afebrile, normal vital signs Gen: NAD, AxO Abd: soft, nontender GU: minimal lochia Ext: no calf tenderness <PERTINENT RESULTS> ___ 12: 26PM BLOOD WBC-9.3 RBC-4.09* Hgb-11.2* Hct-34.0* MCV-83 MCH-27.5 MCHC-33.1 RDW-14.0 Plt ___ ___ 12: 26PM BLOOD Neuts-78.8* Lymphs-15.3* Monos-5.4 Eos-0.4 Baso-0.1 ___ 01: 00PM BLOOD AFP, Maternal Screen-Test ___ 12: 26PM URINE Color-Yellow Appear-Hazy Sp ___ ___ 12: 26PM URINE Blood-TR Nitrite-NEG Protein-TR Glucose-TR Ketone-NEG Bilirub-NEG Urobiln-2* pH-6.5 Leuks-SM ___ 12: 26PM URINE RBC-2 WBC-8* Bacteri-FEW Yeast-NONE Epi-5 ___ 12: 26PM URINE bnzodzp-NEG barbitr-NEG opiates-NEG cocaine-NEG amphetm-NEG mthdone-NEG ___ 12: 26 pm URINE Source: ___. **FINAL REPORT ___ Chlamydia trachomatis, Nucleic Acid Probe, with Amplification (Final ___: Negative for Chlamydia trachomatis by ___ System, APTIMA COMBO 2 Assay. Validated for use on Urine Samples by the ___ Microbiology Laboratory. Performance characteristics on urine samples were found to be equivalent to those of FDA- approved TIGRIS APTIMA COMBO 2 and/or COBAS Amplicor methods. NEISSERIA GONORRHOEAE (GC), NUCLEIC ACID PROBE, WITH AMPLIFICATION (Final ___: Negative for Neisseria gonorrhoeae by ___ System, APTIMA COMBO 2 Assay. Validated for use on Urine Samples by the ___ Microbiology Laboratory. Performance characteristics on urine samples were found to be equivalent to those of FDA- approved TIGRIS APTIMA COMBO 2 and/or COBAS Amplicor methods. ___ 12: 26 pm URINE Source: ___. **FINAL REPORT ___ URINE CULTURE (Final ___: GRAM POSITIVE BACTERIA. >100,000 ORGANISMS/ML.. Alpha hemolytic colonies consistent with alpha streptococcus or Lactobacillus sp. <MEDICATIONS ON ADMISSION> PNV, Fe <DISCHARGE MEDICATIONS> 1. Acetaminophen ___ mg PO Q6H: PRN Pain RX *acetaminophen [Acetaminophen Extra Strength] 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 a day Disp #*40 Capsule Refills: *0 3. 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 <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> previable advanced cervical dilation <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 ___ for an induction termination. You have recovered well and will be discharged home. Please follow the general instructions below. Nothing in the vagina for 6 weeks (No sex, douching, tampons) Do not take more than 4000mg acetaminophen (APAP) in 24 hrs Do not take more than 2400mg ibuprofen in 24 hrs
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On ___, Ms. ___ was brought to labor and delivery for counseling regarding her previable advanced cervical dilation at 19wks gestation. She was afebrile without any evidence of infection. She was thoroughly counseled by ___ regarding the poor prognosis. After discussion of options of expectant management, cerclage, pessary, D&E, and induction termination, she elected for induction termiation. After receiving misoprostol, she became uncomfortable and received a spinal. She then had spontaneous vaginal delivery of a liveborn male fetus which subsquently demised. Please refer to the delivery note for details of the delivery. The placenta was delivered spontaneously. Her postpartum course was uncomplicated. She declined any religious services. She was seen by social work and was coping appropriately. She was discharged home on postpartum day 1.
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10945510-DS-8
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> preeclampsia evaluation <MAJOR SURGICAL OR INVASIVE PROCEDURE> Primary classical c-section Shirodkar cerclage removal <HISTORY OF PRESENT ILLNESS> ___ G5P1 at 27+6, sent to triage today for PIH eval after pressures 140-150 over 90's in office during ___. Pt currently denies HA, visual changes, RUQ/epigastric pain. Denies CTX, VB or LOF. +AFM. Pt currently with 2.5 days left on course of Amox for UTI. Since yesterday feels like she has a yeast infection, vagina is itchy. <PAST MEDICAL HISTORY> PNC: -___: ___ -Labs: B+/Ab-/HBsAg-/RPRNR/RI/HIV-/GBS pend -Screening: ___: T21 1 in 684, T13/T18 <1: 10,000, low ___ -FFS: WNL, BOY! -GLT: elevated 1hr, mildly elevated 3hr, has been checking ___ for past 2 weeks, have been normal -EFW: ___ 21%ile -Issues: *hx indicated cerclage placed at 13w, still in place OBHx: ___ G1 - ___ - 36wk SVD, labor, unsure weight, boy ___, 19wks (presented for fetal anatomy survey at 19 weeks. At that time, her cervix was noted to be 3-cm dilated. She denied contractions, leakage of fluid or vaginal bleeding. She was counseled about management options and was induced with misoprostol ___ sab, no D+C ___ - d+e at 13w5d for HbSC GYNHx: hx of HSV, HPV; no abn paps, fibroids, hx physiologic cyst on left PMHx: Anemia?, G6PD, sickle trait, history of depression (no active thoughts of hurting herself or others, was briefly on Zoloft for a week post partum, discontinued ___ dry mouth), headaches (throbbing, short lived no help with Tylenol) PSHx: wisdom teeth, D+E, cerclage placement, abdominoplasty <SOCIAL HISTORY> ___ <FAMILY HISTORY> Noncontributory <PHYSICAL EXAM> On admission: VS: ___ 16: 04BP: 143/92 (104) ___ ___: 92 ___ 16: 11BP: 142/77 (92) ___ 16: 21BP: 151/85 (101) ___ 16: 31BP: 146/80 (95) ___ 16: 41BP: 146/71 (87) ___ 16: 51BP: 141/87 (97) Gen: NAD CV: RRR Resp: CTAB Abd: gravid, soft, NT Ext: soft, NT, non-edematous, no clonus, 2+ DTR ___: deferred, brief exam of external genitalia with labia pulled back white clumpy discharge visualized NST: 145, mod var, AGA Toco: flat TAUS: VTX, MVP 4.03 On discharge: ___ 0605 Temp: 98.3 PO BP: 129/83 R Lying HR: 91 RR: 18 O2 sat: 98% O2 delivery: RA Pain Score: ___ ___ 0200 Temp: 98.1 PO BP: 115/67 L Lying HR: 78 RR: 18 O2 sat: 98% O2 delivery: Ra Pain Score: ___ ___ 2200 Temp: 98.9 PO BP: 131/83 HR: 87 RR: 18 O2 sat: 99% O2 delivery: RA ___ 1712 Temp: 98.4 PO BP: 130/79 HR: 98 RR: 18 O2 sat: 99% ___ 1312 BP: 138/78 HR: 105 RR: 20 O2 sat: 99% O2 delivery: RA ___ 1130 Temp: 98.0 PO BP: 145/83 HR: 80 RR: 18 O2 sat: 97% O2 delivery: RA Pain Score: ___ ___ 0820 BP: 139/89 manua L BP range ___ Gen: NAD Pulm: nl work of breathing Abd: soft, appropriately TTP, no rebound/guarding, fundus firm below umbi, incision c/d/i GU: scant lochia Ext: nontender without edema <PERTINENT RESULTS> ___ WBC-10.5 RBC-3.72 Hgb-10.2 Hct-30.5 MCV-82 Plt-230 ___ WBC-18.5 RBC-3.84 Hgb-10.6 Hct-31.1 MCV-81 Plt-256 ___ WBC-13.8 RBC-3.94 Hgb-10.8 Hct-32.4 MCV-82 Plt-270 ___ Hct-31.0 ___ Creat-0.7 ALT-19 AST-17 ___ Creat-0.6 ALT-19 AST-17 ___ Creat-0.5 ALT-20 AST-17 ___ BLOOD pO2-19* pCO2-59* pH-7.26* calTCO2-28 Base XS--3 Comment-CORD ___ ___ URINE Blood-NEG Nitrite-NEG Protein-100* Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG ___ URINE RBC-1 WBC-1 Bacteri-NONE Yeast-NONE Epi-<1 ___ URINE Hours-RANDOM Creat-70 TotProt-160 Prot/Cr-2.3* ___ URINE pH-6 Hours-24 Volume-2400 Creat-71 TotProt-254 Prot/Cr-3.6* ___ URINE 24Creat-1704 24Prot-6096 SMEAR FOR BACTERIAL VAGINOSIS (Final ___: GRAM STAIN NEGATIVE FOR BACTERIAL VAGINOSIS. YEAST VAGINITIS CULTURE (Final ___: YEAST. SPARSE GROWTH R/O GROUP B BETA STREP (Final ___: POSITIVE FOR GROUP B BETA STREPTOCOCCI. YEAST VAGINITIS CULTURE (Final ___: YEAST. MODERATE GROWTH <MEDICATIONS ON ADMISSION> Makena IM ___ PNV Fe Colace Amoxacillin 500mg BID <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: PRN Constipation RX *docusate sodium 100 mg 1 capsule(s) by mouth bid prn Disp #*60 Capsule Refills: *2 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: *3 4. Ibuprofen 600 mg PO Q6H: PRN Pain Do not exceed 2400mg in 24 hours RX *ibuprofen 600 mg 1 tablet(s) by mouth q6h prn Disp #*60 Tablet Refills: *0 5. OxyCODONE (Immediate Release) ___ mg PO Q4H: PRN pain ___ cause drowsiness. Do not drive or drink alcohol. Partial fill on pt request. RX *oxycodone 5 mg 1 tablet(s) by mouth q4h prn pain Disp #*5 Tablet Refills: *0 <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> Primary classical c-section Shirodkar cerclage removal Severe pre-eclampsia by blood pressures <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Dear Ms. ___, Congratulations on the birth of your baby. Please refer to your discharge packet and the instructions below: - Nothing in the vagina for 6 weeks (No sex, douching, tampons) - No heavy lifting for 6 weeks - Do not drive while taking 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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___ G5P1 admitted at ___ with preeclampsia by mild range blood pressures and proteinuria (p/c 2.3). She had normal preeclampsia labs and fetal testing was reassuring on admission. She was given a course of betamethasone (complete ___ and the NICU was consulted. On HD#2, ultrasound in the ___ Maternal Fetal Medicine revealed IUGR with an estimated fetal weight in the ___ percentile. In addition, there was absent EDF. On ___, she had nonreassuring fetal testing including minimal variability and intermittent deep variable decelerations. Delivery was recommended. She received magnesium for neuroprotection and was delivered by primary classical cesarean section with removal of Shirodkar cerclage (at 28w2d). She delivered a liveborn male infant weighing 650 grams with Apgars of 4 and 8. Neonatology staff was present for delivery and transferred her neonate immediately for prematurity. Please see operative report for details. She was continued on Magnesium for 24 hours postpartum. She did not require any anti-hypertensives. She otherwise had an uncomplicated postop course and was discharged home on POD#5. She will have close outpatient follow up with a blood pressure check in 2 weeks.
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10949795-DS-19
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Penicillins / phenobarbital / morphine <ATTENDING> ___ ___ Complaint: Endometrial intraepithelial neoplasia status post endometrial ablation. <MAJOR SURGICAL OR INVASIVE PROCEDURE> Robotic-assisted total laparoscopic hysterectomy, bilateral salpingo-oophorectomy, cystoscopy. <HISTORY OF PRESENT ILLNESS> Ms. ___ is a ___ gravida ___ female recently diagnosed with endometrial intraepithelial neoplasia. She reported that she had an extremely heavy period beginning in ___ of this year that lasted for about two months. She described the bleeding as heavy and daily to the point that she was very affected by this. She stated she was not anemic and did not need a blood transfusion, but was ultimately evaluated by Dr. ___. She also underwent a pelvic ultrasound, which was performed on ___ revealing 9.5 x 4.0 x 5.9 cm anteverted uterus. The endometrium was slightly heterogeneous and thickened more focally in the fundal aspect. The ovaries were normal and there was no free fluid. An endometrial biopsy was attempted, but due to difficulty with cervical stenosis she was taken to the operating room and underwent a D&C, hysteroscopy, and NovaSure ablation on ___. At the time of surgery, she was noted to have adhesions and polypoid material, sharp curettage was performed followed by ablation of the endometrial cavity. The final pathology from the curetting revealed a small focus of the endometrial gland crowding with atypia consistent with endometrial intraepithelial neoplasia as well as fragments of endometrial polyp and a background of proliferative endometrium. Since the ablation, the patient had no further bleeding or other problems. The patient had been on birth control pills for about ___ years prior to this past ___ of ___, which she stopped because of concerns about her migraines. She reported being on continuous OCPs and that this really helps to regulate her cycles and keep them under control without any significant bleeding. When coming off of the birth control pill, she subsequently started to have a small amount of irregular spotting or bleeding, but then had a significant period as mentioned above in ___, which prompted the above workup. Prior to this, she had normal menses began at age ___ up until around age ___ when they started to become irregular where she would skip a period every month or so and when she did have a period, they were quite heavy and irregular. <PAST MEDICAL HISTORY> PAST MEDICAL HISTORY: 1. Migraines, which occur on an almost monthly basis and increased during the ___. She reports that these increased as a result of her use of birth control pills, which she did take up, up until this past year. 2. Hypertension. 3. Vertigo. PAST SURGICAL HISTORY: 1. Breast reduction in ___. OB/GYN HISTORY: Menarche at age ___. Menstrual cycle was noted in the HPI. She is a gravida 0. She has had normal regular Pap smears. She is not sexually active. <SOCIAL HISTORY> ___ <FAMILY HISTORY> Notable for father with ___ lymphoma and lung cancer diagnosed in his early ___. Mother deceased of what sound like metastatic lung cancer at age ___. Paternal grandmother with pancreatic cancer and a sister with some sort of precancerous cells affecting her uterus status post ablation. The patient states that this occurred when her sister was ___ years old and she is now ___, which raises question of whether this may have actually been cervical dysplasia. Details are unclear. <PHYSICAL EXAM> On day of discharge: VS: T 97.2, HR 86, BP 128/77, RR 20, O2 99% RA Gen: well-appearing, no acute distress CV: regular rate and rhythm Pulm: clear to auscultation bilaterally Abd: soft, appropriately tender, nondistended, incisions clean/dry/intact with steri-strips, no rebound/guarding GU: pad with minimal staining ___: nontender, nonedematous <PERTINENT RESULTS> ___: 00AM BLOOD WBC-18.3* RBC-4.58 Hgb-13.2 Hct-39.7 MCV-87 MCH-28.8 MCHC-33.2 RDW-13.2 RDWSD-41.4 Plt ___ ___ 08: 20AM BLOOD WBC-13.4* RBC-4.82 Hgb-13.7 Hct-40.7 MCV-84 MCH-28.4# MCHC-33.7 RDW-13.1 RDWSD-40.1 Plt ___ ___ 07: 00AM BLOOD Glucose-122* UreaN-7 Creat-0.7 Na-141 K-3.6 Cl-102 HCO3-27 AnGap-16 ___ 07: 00AM BLOOD Calcium-9.7 Phos-3.4 Mg-2.0 ECG ___: Sinus tachycardia <MEDICATIONS ON ADMISSION> 1. Amlodipine 10 mg qpm 2. Butalbital-aspirin-caffeine 50 mg-325 mg-40 mg capsule prn 3. Meloxicam 7.5 mg tablet prn back pain (last dose 1 mo ago) 4. Metoprolol succinate ER 100 mg 5. Nortriptyline 50 mg capsule qpm 6. Sertraline 50 mg tablet qpm <DISCHARGE MEDICATIONS> 1. Acetaminophen ___ mg PO Q6H: PRN Pain - Mild Do not take >4000mg (8 tablets) in 24h. 2. Docusate Sodium 100 mg PO BID Hold for loose stools. 3. Ibuprofen 600 mg PO Q6H: PRN Pain - Mild Take with food to avoid GI upset. 4. OxyCODONE (Immediate Release) ___ mg PO Q4H: PRN Pain - Moderate ___ cause sedation. Do not drive or combine with alcohol. 5. Acetaminophen-Caff-Butalbital ___ TAB PO Q4H: PRN Headache Do not exceed 6 tablets/day 6. amLODIPine 10 mg PO DAILY 7. Metoprolol Succinate XL 100 mg PO DAILY 8. Nortriptyline 50 mg PO QHS <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> Endometrial intraepithelial neoplasia, final pathology pending <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Dear Ms. ___, . You were admitted to the gynecologic oncology service after undergoing the procedures listed below. You have recovered well after your operation, and the team feels that you are safe to be discharged home. Please follow these instructions: . * Take your medications as prescribed. We recommend you use ibuprofen and Tylenol regularly (every 6 hours) and oxycodone (narcotic) as needed up to every ___ hours. As you start to feel better, try weaning the oxycodone first. * Do not drive while taking narcotics. * Do not combine narcotic and sedative medications or alcohol. * Do not take more than 4000mg acetaminophen (tylenol) in 24 hrs. * No strenuous activity until your post-op appointment. * Nothing in the vagina (no tampons, no douching, no sex) for 8 weeks or as advised by Dr. ___. * No heavy lifting of objects >10 lbs for 4 weeks. * You may eat a regular diet. * It is safe to walk up stairs. . Incision care: * You may shower and allow soapy water to run over incision; no scrubbing of incision. No bath tubs for 6 weeks. * Leave your steri-strips on. If they are still on after ___ days from surgery, you may remove them. . To reach medical records to get the records from this hospitalization sent to your doctor at home, call ___.
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Ms. ___ was admitted to the gynecologic oncology service after undergoing a robotic-assisted total laparoscopic hysterectomy, bilateral salpingectomy, 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, toradol, and acetaminophen. Her diet was advanced without difficulty and she was transitioned to oral acetaminophen, ibuprofen, and oxycodone. On post-operative day #0, her urine output was adequate so her Foley catheter was removed and she voided spontaneously. Her immediate post-operative course was notable for mild tachycardia, up to the 110s. This was felt most likely secondary to sub-optimal pain control. She had an EKG that showed sinus tachycardia. Her POD#1 CBC demonstrated no evidence of blood loss anemia. Her abdominal exam remained reassuring and she had no localizing signs or symptoms. Her tachycardia improved with time and improved pain control and she had a normal heart rate the day of discharge. For her hypertension, anxiety, and migraines, she was continued on her home medications. Her blood pressures remained well controlled. 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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10952540-DS-18
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Patient recorded as having No Known Allergies to Drugs <ATTENDING> ___. <CHIEF COMPLAINT> endometrial intraepithelial neoplasia <MAJOR SURGICAL OR INVASIVE PROCEDURE> laparoscopic assisted vaginal hysterectomy bilateral salpingo-oophorectomy ventral herniorrhaphy <HISTORY OF PRESENT ILLNESS> The patient is a ___ G5, P3 sent by Dr. ___ for a consultation regarding a new diagnosis of EIN. She presented with menometrorrhagia, and endometrial biopsy revealed the above. The slides were reviewed here at ___, and the original reading was confirmed. She states that the bleeding has been heavy at times, although a recent hematocrit was normal at 41.1. She denied any other complaints. <PAST MEDICAL HISTORY> PAST MEDICAL HISTORY: Negative. PAST SURGICAL HISTORY: Left femoral herniorrhaphy, left meniscus repair. OB HISTORY: Vaginal delivery x3. GYN HISTORY: Last Pap smear and mammogram are unknown but were recently normal. <SOCIAL HISTORY> ___ <FAMILY HISTORY> Significant for mother with stomach cancer. <PHYSICAL EXAM> GENERAL: Well developed and thin. HEENT: Sclerae are anicteric. LYMPHATICS: Lymph node survey was negative. LUNGS: Clear to auscultation. HEART: Regular without murmurs. BREASTS: Without masses. ABDOMEN: Soft and nondistended and without palpable masses. There was a hernia in the midline approximately 2 cm above the umbilicus which was about 1.5-2 cm in diameter. It was easily reducible. EXTREMITIES: Without edema. PELVIC: The vulva and vagina were normal. The cervix was normal. Bimanual and rectovaginal examination revealed a small uterus and a normal cervix with no palpable adnexal masses. There was no cul-de-sac nodularity, and the rectal was intrinsically normal. <PERTINENT RESULTS> ___: 08PM BLOOD Hct-33.3* ___ 08: 05AM BLOOD Hct-31.7* <MEDICATIONS ON ADMISSION> Prozac and Valtrex <DISCHARGE MEDICATIONS> 1. Valtrex ___ mg Tablet Sig: One (1) Tablet PO qhs (). 2. Fluoxetine 20 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 3. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed. Disp: *60 Tablet(s)* Refills: *0* 4. Oxycodone-Acetaminophen ___ mg Tablet Sig: ___ Tablets PO Q4H (every 4 hours) as needed. Disp: *60 Tablet(s)* Refills: *0* <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> endometrial intraepithelial neoplasia <DISCHARGE CONDITION> good <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> - Please call your doctor if you experience fever > 100.4, chills, nausea and vomiting, worsening or severe abdominal pain, heavy vaginal bleeding, chest pain, trouble breathing, or if you have any other questions or concerns. Please call if you have redness and warmth around the incision, if your incision is draining pus-like material, or if your incision reopens. - No driving for two weeks and while taking narcotic pain medication as it can make you drowsy. - No heavy lifting or strenuous exercise for 6 weeks to allow your incision to heal adequately. - Nothing per vagina (no tampons, intercourse, douching for 6 weeks. - Please keep your follow-up appointments as outlined below.
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___ was admitted after laparoscopic assisted vaginal hysterectomy and bilateral salpingoophorectomy for endometrial intraepithelial neoplasia by Dr. ___ as well as a ventral herniorrhaphy by Dr. ___. Please see operative report for details. Pt complained of a headache and bloating on POD#1 which resolved with caffeine and ambulation, respectively. Patient received routine post-operative care and was discharged home on POD#1 in good condition.
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10954107-DS-21
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> right upper quadrant pain <MAJOR SURGICAL OR INVASIVE PROCEDURE> ERCP and removal of 2 gallstones <HISTORY OF PRESENT ILLNESS> ___ G4P3 @ 20w4d transfer from ED with gallbladder US concerning for choledocolithiasis. Patient reports three episodes of sudden onset abdominal bloating, back pain, N/V this week usually associated with eating. She has had a total of six similar episodes since ___. They became subsequently worse this week until the patient presented to ___ yesterday and was given IV morphine for pain control. She was transferred to ___ ED last night for further work-up as ultrasound was not available per patient. The work-up in the ED showed abnormal AST/ALT of 174/130 though they were normal at the OSH. Gallbladder US showed a 7mm dilated CBD with no stone visualized though the entire duct was not able to be visualized. Gallstones were present in the gallbladder. In addition, the patient has not sought out regular PNC as she has been very conflicted about whether or not to continue this pregnancy. She was strongly considering termination at the beginning of pregnancy, but was afraid of the emotional toll it would take on her. She met with ___ at ___ after she expressed hesitation about her decision to terminate at her family planning clinic visit on ___. <PAST MEDICAL HISTORY> PNC: *) Dating: ___: ___ by LMP c/w 18wk US *) Labs: O+/ab- Oher PNL not done due to ambivalence re pregnancy *) Routine: - Genetics: LR NIPT - U/S: nl full fetal survey - GLT: no yet done *) Issues - Conflicted about pregnancy termination POBHx: G1 NSVD IUI G2 NSVD IVF G3 NSVD IVF G4 Current PGynHx: Denies STDs or abnl paps PMH: resolved vulvodynia, Vit D deficiency PSH: egg retrieval, polypectomy Meds: PNV All: NKDA SH: Denies EtOH/Smoking/Drugs <SOCIAL HISTORY> SH: Denies EtOH/Smoking/Drugs ___ Caucasian homemaker and mother of three. Born and raised in ___. Lives with husband and three children (ages ___, ___, and ___). Has twin sister who recently delivered first child; no other siblings. Parents lives 25 min away from patient; patient's mother has been very helpful in taking care of her kids. College-educated, used to work in ___ and ___. <PHYSICAL EXAM> Initial PE: VS 98.1 106/53 82 18 Gen: NAD, tearful when speaking about possibly terminating pregnancy Abd: soft, gravid, NT SVE: deferred Ext: NT, no edema FHR: 140s <PERTINENT RESULTS> ___ 08: 06AM BLOOD WBC-6.2 RBC-3.14* Hgb-10.1* Hct-28.8* MCV-92 MCH-32.1* MCHC-35.0 RDW-15.0 Plt ___ ___ 04: 58AM BLOOD WBC-5.4 RBC-3.24* Hgb-10.4* Hct-29.5* MCV-91 MCH-32.3* MCHC-35.4* RDW-14.7 Plt ___ ___ 03: 52PM BLOOD WBC-8.1 RBC-3.58* Hgb-11.4* Hct-32.4* MCV-91 MCH-31.8 MCHC-35.2* RDW-14.5 Plt ___ ___ 11: 00AM BLOOD WBC-8.0 RBC-3.29* Hgb-10.6* Hct-30.4* MCV-92 MCH-32.2* MCHC-34.9 RDW-14.8 Plt ___ ___ 12: 25PM BLOOD WBC-9.0# RBC-3.62* Hgb-11.6* Hct-33.8* MCV-93 MCH-32.0 MCHC-34.3 RDW-15.0 Plt ___ ___ 04: 58AM BLOOD Neuts-79.0* Lymphs-16.2* Monos-3.9 Eos-0.5 Baso-0.4 ___ 03: 52PM BLOOD Neuts-83.8* Lymphs-12.1* Monos-3.8 Eos-0.2 Baso-0.1 ___ 11: 00AM BLOOD Neuts-83.7* Lymphs-12.7* Monos-3.2 Eos-0.3 Baso-0.1 ___ 11: 00AM BLOOD Glucose-81 UreaN-7 Creat-0.4 Na-136 K-3.8 Cl-103 HCO3-22 AnGap-15 ___ 12: 25PM BLOOD ALT-11 AST-17 AlkPhos-64 TotBili-0.3 ___ 11: 00AM BLOOD ALT-130* AST-174* AlkPhos-100 TotBili-1.9* ___ 03: 52PM BLOOD ALT-137* AST-165* AlkPhos-119* TotBili-3.1* DirBili-2.4* IndBili-0.7 ___ 04: 58AM BLOOD ALT-113* AST-111* AlkPhos-127* TotBili-4.6* DirBili-3.9* IndBili-0.7 ___ 08: 06AM BLOOD ALT-87* AST-62* TotBili-0.9 DirBili-0.4* IndBili-0.5 ___ 12: 25PM BLOOD TotProt-6.4 Albumin-4.0 Globuln-2.4 ___ 08: 06AM BLOOD HBsAg-NEGATIVE ___ 08: 06AM BLOOD HIV Ab-NEGATIVE RAPID PLASMA REAGIN TEST (Final ___: NONREACTIVE. Reference Range: Non-Reactive. RUBELLA IgG SEROLOGY (Pending): <MEDICATIONS ON ADMISSION> prenatal vitamins <DISCHARGE MEDICATIONS> prenatal vitamins <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> Choledocolithiasis <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> low fat diet follow up with PCP and OB/GYN this week
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On ___ Ms. ___ was admitted to the ___ service for management of choledocolithiasis. She underwent an uncomplicated ERCP on ___ after thoroughly discussing the risks and benefits with her ___ OB team and an MFM consultation. Of note this pregnancy has been complicated by ambivalence regarding continuation of this unplanned pregnancy. She was again offered social work to continue this discussion but she declined. Her post procedure course was uncomplicated and her diet was easily advanced to a regular low fat diet.
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10958320-DS-21
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> fall <MAJOR SURGICAL OR INVASIVE PROCEDURE> none <HISTORY OF PRESENT ILLNESS> Ms. ___ is a ___ G3P1 who presented at ___ w/ posterior placenta for pink spotting this morning w/ wiping s/p fall last night ___. No bleeding on panty liner that she put on today since using the bathroom. Pt reports a fall down half a flight of stairs yesterday ___ at 9pm landing on her back and buttocks. Pt thinks she may have struck left side of abdomen on hand rail. Denies LOC, VB or CTX after the fall. Pt reports +AFM last night and reports that she has felt movement this morning though not as vigorously, this afternoon movement has returned to normal. Pt took Tylenol ___ at 11pm last night for back pain. Today mild abd cramping. Denies LOF. <PAST MEDICAL HISTORY> Prenatal Course: ___ ___ O pos/ab neg/HIV neg/HepBsAg neg/RPR NR/Rub ___ pending Low risk ERA Normal FFS Normal GLT OB history: G1- ___ - ___ wk SVD 6#9 oz, uncomplicated G2- ___ - sAB - office MVA. pt reports she was 13 weeks G3- current Gyn history: H/o LSIL pap, normal f/u Paps. Denies history of STIs. PMH: Denies PSH: laparoscopic appendectomy <SOCIAL HISTORY> ___ <FAMILY HISTORY> NC <PHYSICAL EXAM> <PHYSICAL EXAM> -VS: T 98.7, HR 83, RR 16, BP 95/58 -Gen: NAD -Abd: gravid, soft, very minimally TTP left side of abdomen, no evidence of trauma, no ecchymosis or abrasions. -SSE: physiologic discharge, no blood, cervix visually closed -SVE: inner OS closed/long/posterior, unchanged over 4 hours -NST: baseline 130 -Toco: irritable vs. ctx q1-3min, pt comfortable, unaware -TAUS: VTX, MVP 6.2 <PERTINENT RESULTS> ___ 08: 45AM BLOOD WBC-9.8 RBC-3.28* Hgb-9.5* Hct-29.8* MCV-91 MCH-29.0 MCHC-31.9* RDW-11.9 RDWSD-39.5 Plt ___ ___ 02: 12PM BLOOD WBC-9.3 RBC-3.65* Hgb-10.8* Hct-33.0* MCV-90 MCH-29.6 MCHC-32.7 RDW-12.1 RDWSD-39.8 Plt ___ ___ 02: 12PM BLOOD ___ PTT-28.7 ___ ___ 02: 12PM BLOOD ___ 02: 20PM URINE Color-Yellow Appear-Hazy Sp ___ ___ 02: 20PM URINE Blood-NEG Nitrite-NEG Protein-TR Glucose-NEG Ketone-150 Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG ___ 02: 20PM URINE RBC-0 WBC-2 Bacteri-FEW Yeast-NONE Epi-1 ___ 2: 20 pm URINE Source: ___. **FINAL REPORT ___ URINE CULTURE (Final ___: NO GROWTH. ___ 1: 50 pm ANORECTAL/VAGINAL CULTURE Source: Anorectal/Vaginal. **FINAL REPORT ___ R/O GROUP B BETA STREP (Final ___: NEGATIVE FOR GROUP B BETA STREP. <MEDICATIONS ON ADMISSION> 1. Prenatal Vitamins 1 TAB PO DAILY <DISCHARGE MEDICATIONS> 1. Prenatal Vitamins 1 TAB PO DAILY 2. Ferrous Sulfate 325 mg PO DAILY RX *ferrous sulfate 325 mg (65 mg iron) ___ tablet(s) by mouth once a day Disp #*60 Tablet Refills: *3 3. Docusate Sodium 100 mg PO BID RX *docusate sodium 100 mg ___ tablet(s) by mouth twice a day Disp #*60 Tablet Refills: *3 <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> preterm contractions, anemia <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Dear Ms ___, You were admitted to the hospital for preterm contractions after a fall. You were given betamethasone, a steroid which helps the baby's lungs among other benefits. You had ultrasound testing of the baby which was reassuring. Your contractions improved and cervical exam remained stable and you are now safe to be discharged home. Please take an iron supplement in addition to your prenatal vitamin. Please take with a stool softener to prevent constipation. Please call the office for: - Worsening, painful or regular contractions - Vaginal bleeding - Leakage of water or concern that your water broke - Abdominal pain - Nausea/vomiting - Fever, chills - Decreased fetal movement - Other concerns
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Ms. ___ is a ___ G3P1 who presented at 30w4d with pink spotting on wipe after a fall ___ found to have preterm contraction, no e/o preterm labor. Her cervical exams were stable and closed. She had reassuring lab and coag testing upon admission and no sonographic e/o abruption on US. She had reassuring fetal NST and was made betamethasone complete ___. She had no further bleeding and her contractions improved. She was discharged home in stable condition on hospital day 3 with outpatient follow-up.
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10960232-DS-14
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Neosporin Scar Solution <ATTENDING> ___ <CHIEF COMPLAINT> Pelvic organ prolapse, stress incontinence <MAJOR SURGICAL OR INVASIVE PROCEDURE> ___ colpocleisis, perineorrhaphy, TVT, cystoscopy <PHYSICAL EXAM> Discharge physical exam Vitals: VSS Gen: NAD, A&O x 3 CV: RRR Resp: no acute respiratory distress Abd: soft, appropriately tender, no rebound/guarding, incision c/d/i Ext: no TTP <MEDICATIONS ON ADMISSION> The Preadmission Medication list may be inaccurate and requires futher investigation. 1. Lisinopril 10 mg PO DAILY 2. Atenolol 50 mg PO DAILY 3. Atorvastatin 10 mg PO QPM 4. Triamterene-HCTZ (37.5/25) 1 CAP PO DAILY 5. Potassium Chloride 20 mEq PO DAILY 6. Aspirin 81 mg PO DAILY <DISCHARGE MEDICATIONS> 1. Acetaminophen 650 mg PO TID RX *acetaminophen 650 mg 1 tablet(s) by mouth every 6 hours Disp #*50 Tablet Refills: *0 2. Docusate Sodium 100 mg PO BID RX *docusate sodium 100 mg 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills: *0 3. Ibuprofen 400 mg PO Q8H: PRN Pain - Moderate RX *ibuprofen 400 mg 1 tablet(s) by mouth every 6 hours Disp #*40 Tablet Refills: *0 4. TraMADol 25 mg PO Q6H: PRN pain RX *tramadol 50 mg ___ to 1 tablet(s) by mouth every 6 hours Disp #*30 Tablet Refills: *0 5. Atenolol 75 mg PO QAM 6. Aspirin 81 mg PO DAILY 7. Atorvastatin 10 mg PO QPM 8. Lisinopril 10 mg PO DAILY 9. Potassium Chloride 20 mEq PO DAILY Hold for K > 10. Triamterene-HCTZ (37.5/25) 1 CAP PO DAILY <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> pelvic organ prolapse and stress incontinence <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Dear Ms. ___, You were admitted to the gynecology service after your procedure. You have recovered well and the team believes you are ready to be discharged home. Please call Dr. ___ office with any questions or concerns. Please follow the instructions below. General instructions: * Take your medications as prescribed. * Do not drive while taking narcotics. * Take a stool softener such as colace while taking narcotics to prevent constipation. * Do not combine narcotic and sedative medications or alcohol. * Do not take more than 4000mg acetaminophen (APAP) in 24 hrs. * No strenuous activity until your post-op appointment. * Nothing in the vagina * No 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 ___ colpocleisis, perineorrhaphy, tension free vaginal tape, 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 morphine. On post-operative day 1, her urine output was adequate so her foley was removed and she passed a trial of void. Her diet was advanced without difficulty and she was transitioned to PO tramadol, acetaminophen, and low dose motrin. For her history of hypertension, she was continued on atenolol. For her history of renal insufficiency, toradol was held. 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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10960463-DS-20
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> nuts / verapamil / Tegretol / lisinopril / Enablex / Lipitor / pravastatin / simvastatin / epinephrine / Demerol / Sulfa (Sulfonamide Antibiotics) / Penicillins / Plaquenil / skin prep solution in procedure room <ATTENDING> ___. <CHIEF COMPLAINT> high grade serous presumed ovarian cancer <MAJOR SURGICAL OR INVASIVE PROCEDURE> EXPLORATORY LAPAROTOMY, INTERVAL CYTOREDUCTIVE SURGERY, TOTAL ABDOMINAL HYSTERECTOMY, BILATERAL SALPINGO-OOPHORECTOMY, OMENTECTOMY, RESECTION OF NODULE FROM LIVER SURFACE, PLASMA JET ABLATION OF DIAPHRAGMATIC AND MESENTERIC NODULES <5MM, CYSTOSCOPY, AND SUBTOTAL COLECTOMY, END ILEOSTOMY (___) <HISTORY OF PRESENT ILLNESS> DIAGNOSIS: Stage ___ high grade serous ___ MEDICAL ONCOLOGIST: Dr. ___ INTERVAL HISTORY: ___ is a lovely ___ yo G3P3 undergoing neoadjuvant chemotherapy for a high grade serous presumed ovarian cancer. Her full oncologic history is detailed below. Most recently she has had a CA125 which continues to drop to 186 most recently (from peak of 697) and a CT scan which shows continued response at all sites of disease, still with significant pelvic mass encasing sigmoid colon and surface liver, omental and mesenteric lesions all decreased in size. Of note, chest CT demonstrated an asymptomatic subsegmental PE last week and patient was initiated on Lovenox. Today, patient reports she is doing well. With exception of an episode of SVT this morning. This is a longstanding issue for her but has not been an active issue. She report previous episodes would last for less than a minute - this episode lasted nearly 20 mins which prompted her and her husband to call ___, as the paramedics arrived she spontaneously converted and she has felt fine ever since with normal HR. Her GI symptoms have dramatically improved since earlier in her disease course. She reports today her bowel function is fairly normal with BMs once a day on average. She does endorse some significant fatigue for the first 2 weeks after treatments, but feels well the ___ week. The only other issue she reported today was that she was told her port needed TPA after her CT scan last week and she plans to go up to heme onc to review with them after this visit. Patient has not seen genetics yet. A complete 10 pt review of systems is notable only for the SVT episode now resolved and fatigue and weakness and is otherwise entirely negative. ONCOLOGIC HISTORY: * ___: Sx of early satiety prompting extensive GI evaluation. * ___: Abdominal ultrasound showing a right hepatic lobe complex liver cyst, normal pancreas, spleen, kidneys. In ___ she also had an abdominal ultrasound showing hepatic cysts. She underwent upper endoscopy showing mild antral gastritis and gastroparesis. Biopsies were obtained and normal. She was treated presumptively for colitis. * ___: Developed joint pains, seen by rheumatology. Dx w/either RA or lupus and started her on prednisone and Plaquenil. Plaquenil stopped ___ to rash. * ___: Found to have a skin lesion on her R leg that was biopsied and found to be melanoma. She then underwent a larger excision for this. * ___: After several months of worsened bloating, abd discomfort, diarrhea, early satiety she presented to the ___ ER and CT scan showed diffuse metastatic disease and a pelvic mass, thus she was transferred to ___. * ___: Admitted to ___ and workup ___ omental bx that showed high-grade serous mullerian adenocarcinoma. Chest CT without overt metastatic disease though some prominent suspicious LNs. * ___: ___ admission for bowel obstruction, diarrhea, bloody stools. Also had paracentesis for 4L and thoracentesis as well - ___ was positive for malignant cells. She had 2 cycles of chemotherapy as inpt. * ___ C1D1 ___ only AUC 5 * ___ C2D1 ___ AUC5/Taxol (30% dose reduction) * ___: C3D1 ___ AUC6/Taxol (20% dose reduction) * ___: C4D1 ___ AUC 5/Taxol (20% dose reduction) * ___: Interval CT detailed below <PAST MEDICAL HISTORY> PMH: - Malignant melanoma, R lower leg as above - SVT - RA versus SLE ongoing Rheum work-up/mgmt. - HTN - Raynaud's disease - Diverticulosis PSH: - 3 C-sections thank you ___ - Deep excision of R lower leg melanoma POBHx: G3P3 - 3 C-sections PGYNHx: Menarche ___, menopause at ___. Not sexually active. Took HRT for 6 months at ___. Denies history of abnormal Pap smears, last Pap ___ years ago. Last GYN exam ___. Denies history of STDs or pelvic infections or other gynecologic problems. MEDICATIONS: - Atenolol 50mg daily - Omeprazole 20 mg daily - Immodium 2 mg daily - Prednisone 10mg daily - Lovenox 60mg SC BID ALLERGIES: - Sulfa - serum sickness - PCN - rash - EES - increased BMs (sensitivity) - Tegretol - increased LFTs - Demerol - unknown rxn as ___ yrs ago - Simvastatin/Pravastatin - increased LFTs - Lipitor - muscle cramps - Verapamil - tachycardia - Nuts/seeds - microscopic colitis - Lisnopril - Hyperkalemia - Plaquenil - torso rash - Sensitivity to dental epinephrine - "Caremark tussin" -hives NOT Latex allergic HCM: - Colonoscopy: ___, diverticulosis - Mammogram: ___, normal - BMD: ___ yrs ago - PCP ___: ___ <SOCIAL HISTORY> ___ <FAMILY HISTORY> FH: No family history of breast, ovarian, uterine cancers. A paternal uncle had colon cancer in his ___. Father had prostate cancer and mother had gastric cancer. Several family members have had melanoma including her son, brother all are doing well. <PHYSICAL EXAM> --======== PREOPERATIVE PHYSICAL EXAM --======== BP: 123/62 Heart Rate: 92. Weight: 134 (With Clothes; With Shoes). BMI: 21.8. CONSTITUTIONAL: Well appearing, NAD NEURO: A&Ox3, normal, using wheelchair due to weakness, but is able to ambulate PSYCH: Normal affect HEENT: NCAT, EOMI, Sclera anicteric, Neck supple, no masses LYMPH NODES: No supraclavicular, cervical or inguinal adenopathy. PULM: CTAB, no wheeze, crackles, decreased BS at bases bilaterally CV: RRR, normal S1 and S2 GI: Soft minimally distended, nontender. Midline mass palpable just inferior to umbilicus, slightly tender to deep palpation. Some fullness/firmness in upper abdomen in midline extending laterally, nontender. No hepatosplenomegaly appreciated. No FLUID WAVE. GU: No CVA tenderness, NEFG, normal urethral meatus. Normal vaginal vault no blood or discharge, cervix without lesions. Bimanual: Smooth vaginal walls, cervix without lesions. Small, minimally mobile, anteverted uterus, large pelvic mass filling cul-de-sac, with minimal mobility smaller than prior, nontender. Rectovaginal: Normal tone, smooth RV septum, pelvic mass palpable with ? surface or peritoneal nodularity but no invasion of rectum palpable. MSK: Extremities WWP. ___ bilateral without edema, nontender. No erythema or warmth or cords palpable. --======== PHYSICAL EXAM ON DISCHARGE: --======== 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 --======== ___ 08: 00AM BLOOD CA125: 186* ___ 11: 00AM BLOOD CA125: 200* ___ 08: 30AM BLOOD CA125: 264* ___ 05: 35AM BLOOD CA125: 346* ___ 06: 10AM BLOOD CA125: 351* ___ 06: 45AM BLOOD CEA: 0.4 CA125: 697* --======== IMAGING ON ADMISSION --======== EXAMINATION: ___ DUP EXTEXT BIL (MAP/DVT) ___ INDICATION: ___ year old woman with stage ___ ovarian cancer and newly diagnosed subsegmental PE// please eval for ___ TECHNIQUE: Grey scale, color, and spectral Doppler evaluation was performed on the left lower extremity veins. COMPARISON: None. FINDINGS: There is normal compressibility and color flow of the bilateral common femoral, femoral, and popliteal veins. Normal color flow and compressibility are demonstrated in the posterior tibial and peroneal veins. There is normal respiratory variation in the common femoral veins bilaterally. IMPRESSION: No evidence of deep venous thrombosis in the bilateral lower extremity veins. __________________________________________ EXAMINATION: CTA CHEST ___ INDICATION: ___ year old woman with metastatic ovarian cancer and PE diagnosed 1 month ago// pre-operative interval evaluation of chest COMPARISON: CT chest dated ___. FINDINGS: The aorta and its major branch vessels are patent, with no evidence of stenosis, occlusion, dissection, or aneurysmal formation. There is no evidence of penetrating atherosclerotic ulcer or aortic arch atheroma present. The pulmonary arteries are well opacified to the subsegmental level, with no evidence of filling defect within the main, right, left, lobar, segmental or subsegmental pulmonary arteries. The main and right pulmonary arteries are normal in caliber, and there is no evidence of right heart strain. There is redemonstration of right basilar airspace disease with interval resolution of the small right pleural effusion. There is no supraclavicular, axillary, mediastinal, or hilar lymphadenopathy. The thyroid gland appears unremarkable. There is no evidence of pericardial effusion. There is no pleural effusion. There is no evidence of pulmonary parenchymal abnormality. The airways are patent to the subsegmental level. Limited images of the upper abdomen are unremarkable. There is redemonstration of a large lobulated cyst at the dome of the liver, unchanged from prior study and better characterized on CT abdomen and pelvis dated ___. No lytic or blastic osseous lesion suspicious for malignancy is identified. There is redemonstration of a compression deformity of the T8 vertebral body, unchanged in appearance compared to prior study. IMPRESSION: 1. No evidence of pulmonary embolism or aortic abnormality. 2. Redemonstration of right basilar airspace disease with interval resolution of the right pleural effusion --======== RELEVANT LABS: --======== CBC ___ 01: 05PM BLOOD WBC-6.9 RBC-3.93 Hgb-10.5* Hct-34.8 MCV-89 MCH-26.7 MCHC-30.2* RDW-18.6* RDWSD-60.7* Plt ___ ___ 08: 53PM BLOOD WBC-11.1* RBC-4.69 Hgb-12.8 Hct-39.9 MCV-85 MCH-27.3 MCHC-32.1 RDW-18.3* RDWSD-55.7* Plt ___ ___ 04: 35AM BLOOD WBC-9.2 RBC-4.56 Hgb-12.4 Hct-37.3 MCV-82 MCH-27.2 MCHC-33.2 RDW-18.2* RDWSD-52.2* Plt ___ ___ 12: 14PM BLOOD WBC-11.7* RBC-4.26 Hgb-11.5 Hct-35.5 MCV-83 MCH-27.0 MCHC-32.4 RDW-18.8* RDWSD-55.4* Plt ___ ___ 02: 09AM BLOOD WBC-13.9* RBC-3.90 Hgb-10.5* Hct-32.4* MCV-83 MCH-26.9 MCHC-32.4 RDW-18.5* RDWSD-54.8* Plt ___ ___ 06: 51AM BLOOD WBC-19.1* RBC-4.39 Hgb-11.8 Hct-36.9 MCV-84 MCH-26.9 MCHC-32.0 RDW-18.0* RDWSD-54.6* Plt ___ ___ 05: 31AM BLOOD WBC-11.3* RBC-3.38* Hgb-9.2* Hct-29.5* MCV-87 MCH-27.2 MCHC-31.2* RDW-17.4* RDWSD-56.0* Plt ___ ___ 05: 28AM BLOOD WBC-11.4* RBC-3.41* Hgb-9.1* Hct-29.7* MCV-87 MCH-26.7 MCHC-30.6* RDW-17.2* RDWSD-55.2* Plt ___ ___ 05: 11AM BLOOD WBC-11.4* RBC-3.47* Hgb-9.4* Hct-30.1* MCV-87 MCH-27.1 MCHC-31.2* RDW-17.1* RDWSD-53.5* Plt ___ ___ 05: 36AM BLOOD WBC-10.3* RBC-3.44* Hgb-9.4* Hct-30.0* MCV-87 MCH-27.3 MCHC-31.3* RDW-17.2* RDWSD-54.8* Plt ___ ___ 05: 37AM BLOOD WBC-9.1 RBC-3.44* Hgb-9.4* Hct-29.7* MCV-86 MCH-27.3 MCHC-31.6* RDW-16.7* RDWSD-52.8* Plt ___ DIFFERENTIAL ___ 01: 05PM BLOOD Neuts-73.6* Lymphs-16.3* Monos-8.9 Eos-0.0* Baso-0.6 Im ___ AbsNeut-5.11 AbsLymp-1.13* AbsMono-0.62 AbsEos-0.00* AbsBaso-0.04 ___ 08: 53PM BLOOD Neuts-80.3* Lymphs-10.8* Monos-8.0 Eos-0.0* Baso-0.4 Im ___ AbsNeut-8.88* AbsLymp-1.20 AbsMono-0.88* AbsEos-0.00* AbsBaso-0.04 ___ 04: 35AM BLOOD Neuts-80.4* Lymphs-10.7* Monos-8.3 Eos-0.0* Baso-0.1 Im ___ AbsNeut-7.37* AbsLymp-0.98* AbsMono-0.76 AbsEos-0.00* AbsBaso-0.01 ___ 06: 51AM BLOOD Neuts-86.4* Lymphs-7.6* Monos-5.2 Eos-0.1* Baso-0.1 AbsNeut-16.81* AbsLymp-1.48 AbsMono-1.01* AbsEos-0.02* AbsBaso-0.02 ___ 05: 31AM BLOOD Neuts-86.1* Lymphs-7.6* Monos-4.9* Eos-0.4* Baso-0.2 Im ___ AbsNeut-9.72* AbsLymp-0.86* AbsMono-0.55 AbsEos-0.04 AbsBaso-0.02 ___ 05: 28AM BLOOD Neuts-82.0* Lymphs-9.9* Monos-6.0 Eos-1.1 Baso-0.2 Im ___ AbsNeut-9.36* AbsLymp-1.13* AbsMono-0.68 AbsEos-0.13 AbsBaso-0.02 ___ 05: 11AM BLOOD Neuts-83.1* Lymphs-9.0* Monos-6.4 Eos-0.7* Baso-0.2 Im ___ AbsNeut-9.46* AbsLymp-1.02* AbsMono-0.73 AbsEos-0.08 AbsBaso-0.02 ___ 05: 36AM BLOOD Neuts-79.5* Lymphs-11.9* Monos-6.3 Eos-0.9* Baso-0.2 Im ___ AbsNeut-8.20* AbsLymp-1.23 AbsMono-0.65 AbsEos-0.09 AbsBaso-0.02 ___ 05: 37AM BLOOD Neuts-79.1* Lymphs-11.7* Monos-6.4 Eos-1.1 Baso-0.2 Im ___ AbsNeut-7.21* AbsLymp-1.07* AbsMono-0.58 AbsEos-0.10 AbsBaso-0.02 Coags ___ 02: 09AM BLOOD ___ PTT-28.6 ___ BMP ___ 01: 05PM BLOOD Glucose-94 UreaN-10 Creat-0.7 Na-142 K-4.5 Cl-99 HCO3-30 AnGap-13 ___ 08: 53PM BLOOD Glucose-183* UreaN-13 Creat-0.7 Na-137 K-5.1 Cl-103 HCO3-23 AnGap-11 ___ 04: 35AM BLOOD Glucose-156* UreaN-14 Creat-0.9 Na-139 K-4.8 Cl-103 HCO3-22 AnGap-14 ___ 02: 09AM BLOOD Glucose-130* UreaN-17 Creat-0.6 Na-132* K-4.6 Cl-99 HCO3-26 AnGap-7* ___ 06: 51AM BLOOD Glucose-120* UreaN-18 Creat-0.6 Na-135 K-3.9 Cl-98 HCO3-27 AnGap-10 ___ 05: 31AM BLOOD Glucose-66* UreaN-14 Creat-0.3* Na-139 K-3.1* Cl-110* HCO3-23 AnGap-6* ___ 05: 28AM BLOOD Glucose-89 UreaN-10 Creat-0.5 Na-139 K-3.7 Cl-101 HCO3-27 AnGap-11 ___ 05: 11AM BLOOD Glucose-86 UreaN-8 Creat-0.5 Na-136 K-3.6 Cl-98 HCO3-29 AnGap-9* ___ 05: 36AM BLOOD Glucose-78 UreaN-8 Creat-0.5 Na-136 K-3.9 Cl-98 HCO3-28 AnGap-10 ___ 05: 37AM BLOOD Glucose-85 UreaN-8 Creat-0.5 Na-134* K-3.6 Cl-94* HCO3-29 AnGap-11 Ca/Mg/Phos ___ 01: 05PM BLOOD Calcium-9.2 Phos-4.4 Mg-1.9 ___ 08: 53PM BLOOD Calcium-7.5* Phos-5.0* Mg-1.4* ___ 04: 35AM BLOOD Calcium-8.6 Phos-5.5* Mg-2.4 ___ 02: 09AM BLOOD Calcium-8.2* Phos-3.2 Mg-1.5* ___ 06: 51AM BLOOD Calcium-8.4 Phos-3.2 Mg-1.8 ___ 05: 31AM BLOOD Calcium-6.0* Phos-2.8 Mg-1.4* ___ 05: 28AM BLOOD Calcium-7.6* Phos-3.6 Mg-1.9 ___ 05: 11AM BLOOD Calcium-7.8* Phos-3.7 Mg-1.6 ___ 05: 36AM BLOOD Calcium-7.9* Phos-3.8 Mg-1.6 ___ 05: 37AM BLOOD Calcium-7.7* Phos-3.6 Mg-1.8 URINALYSIS ___ 06: 37PM URINE Color-Yellow Appear-Clear Sp ___ ___ 06: 37PM URINE Blood-NEG Nitrite-NEG Protein-TR* Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG ___ 06: 37PM URINE RBC-1 WBC-1 Bacteri-NONE Yeast-NONE Epi-1 TransE-<1 ___ 06: 37PM URINE Mucous-OCC* --======== RELEVANT MICROBIOLOGY: --======== ___ 9: 39 am URINE Source: ___. **FINAL REPORT ___ URINE CULTURE (Final ___: NO GROWTH. <MEDICATIONS ON ADMISSION> The Preadmission Medication list is accurate and complete. 1. PredniSONE 7.5 mg PO DAILY 2. Atenolol 50 mg PO QAM 3. Enoxaparin Sodium 60 mg SC Q12H Start: ___, First Dose: Next Routine Administration Time 4. Omeprazole 20 mg PO DAILY 5. Nitrofurantoin Monohyd (MacroBID) 100 mg PO Q12H <DISCHARGE MEDICATIONS> 1. Acetaminophen ___ mg PO Q6H: PRN Pain - Mild/Fever RX *acetaminophen 500 mg ___ tablet(s) by mouth every 6 hours Disp #*50 Tablet Refills: *2 2. Ibuprofen 600 mg PO Q6H: PRN Pain - Mild RX *ibuprofen 600 mg 1 tablet(s) by mouth every 6 hours Disp #*40 Tablet Refills: *2 3. OxyCODONE (Immediate Release) 5 mg PO Q6H: PRN Pain - Severe RX *oxycodone 5 mg ___ tablet(s) by mouth every ___ hours Disp #*40 Tablet Refills: *0 4. Atenolol 50 mg PO DAILY 5. Enoxaparin Sodium 60 mg SC Q12H RX *enoxaparin 60 mg/0.6 mL 60 mg subcutaneous twice a day Disp #*56 Syringe Refills: *2 6. Omeprazole 20 mg PO DAILY 7. PredniSONE 7.5 mg PO DAILY <DISCHARGE DISPOSITION> Home With Service Facility: ___ <DISCHARGE DIAGNOSIS> stage IV high grade serous mullerian 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: Abdominal instructions: * Your staples will be removed within 2 weeks from your surgery. This appointment should already been scheduled for you. Please call if you do not have an appointment scheduled. * Take your medications as prescribed. We recommend you take non-narcotics (i.e. Tylenol, ibuprofen) regularly for the first few days post-operatively, and use the narcotic as needed. As you start to feel better and need less medication, you should decrease/stop the narcotic first. * Do not drive while taking narcotics. * Do not combine narcotic and sedative medications or alcohol. * Do not take more than 4000mg acetaminophen (tylenol) in 24 hrs. * No strenuous activity until your post-op appointment. * Nothing in the vagina (no tampons, no douching, no sex) for 12 weeks. * No heavy lifting of objects >10 lbs for 6 weeks. * You may eat a regular diet. * It is safe to walk up stairs. * Do not put anything in the rectum (suppository, enema, etc) for 6 months, unless advised otherwise by your doctor. Incision care: * You may shower and allow soapy water to run over incision; no scrubbing of incision. No bath tubs for 6 weeks. * If you have staples, they will be removed at your follow-up visit. Ileostomy: * You have a new ileostomy and stool no longer passes through the colon (part of the body where water is reabsorbed back into the body) so your output will be liquid. * The most common complication from an ileostomy is dehydration. * You must measure your ileostomy output for the next few weeks- please bring your I&O sheet to your post-op appointment. The output should be no less than 500cc or greater than 1200cc per day. If you find that your output has become too much or too little, please call the office. * Please monitor for signs and symptoms of dehydration, if you notice these symptoms please call the office or go to the emergency room. You will need to keep yourself well hydrated, if you notice your ileostomy output increasing, drink liquids with electrolytes such as Gatorade. * Please monitor the appearance of your stoma and care for it as instructed by the ostomy nurses. ___ you notice that the stoma is turning darker blue or purple please call the office or go to the emergency room. The stoma may ooze small amounts of blood at times when touched which will improve over time. Monitor the skin around the stoma for any bulging or signs of infection. * You will follow up with the ostomy nurses in the clinic ___ weeks after surgery. You will also have a visiting nurse at home for the next few weeks to help to monitor your ostomy until you are comfortable caring for it on your own. 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 Lovenox injections: * Patients having surgery for cancer have risk of developing blood clots after surgery. This risk is highest in the first four weeks after surgery. You will be discharged with a daily Lovenox (blood thinning) medication. This is a preventive dose of medication to decrease your risk of a forming a blood clot. A visiting nurse ___ assist you in administering these injections.
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___ course ___ PMH stage ___ high grade serous mullerian adenocarcinoma s/p 5 cycles chemo (last ___, subsegmental PE (___), who was admitted to the ICU post op D1 from ex-lap with TAH, BSO, omentectomy, resection of liver nodule, plasma jet ablation, subtotal colectomy with end ileostomy for post-op hypotension. #Ovarian cancer s/p debulking surgery c/b post-op hypotension #Shock Patient with procedural blood loss, and chronic steroid use, who was weaned off pressors with fluid resuscitation and stress dose steroids. Epidural catheter was also removed. Pain was controlled with dilaudid PCA. #History of SVT: Started atenolol 25mg, home dose 50mg. #History of PE: She is on Lovenox at home, but gave SQH for DVT ppx while epidural in place. #Rheumatoid arthritis vs lupus: She was first started on prednisone in ___ and was initially on 20mg daily. At the end of ___ she was decreased to 10mg daily and just a few weeks prior to admission was decreased to 7.5mg daily. Stress dose steroids were provided in the ICU. #Deconditioning post-op Physical therapy was consulted. _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ ________________________________________________________________ GYN ONC ADMISSION Ms. ___ was admitted to the ___ ICU from ___ for intermittent post-operative pressor requirement after undergoing exploratory laparotomy and interval cytoreductive surgery, including total abdominal hysterectomy, bilateral salpingo-oophorectomy, omentectomy, resection of nodule from liver surface, plasma jet ablation, subtotal colectomy and end ileostomy for stage ___ high grade serous mullerian adenocarcinoma. Please see the operative report for full details. She was called out of the ICU on ___ and admitted to the gynecologic oncology service for continued management of her post-operative care. Her post-operative course is detailed as follows: *) Post-op Immediately postoperatively, her pain was controlled with an epidural. Given her hypotension, she was promptly transitioned to a Dilaudid PCA. On post-operative day #2, her urine output was adequate so her Foley catheter was removed and she voided spontaneously. Her diet was advanced slowly. She was maintained on a clear liquid diet and backed down to NPO on post-operative day #3 due to nausea. Her nausea improved, and she was restarted on clear liquids on post-operative day #4. She was transitioned to PO Tylenol/oxycodone on post-operative day #4. She developed urinary retention after catheter removal, and her Foley was replaced on post-operative day #5 for bladder rest. She furthermore complained of irritative voiding symptoms; a UA and urine culture were negative. On post-operative day #7, she had return of flatus and was advanced to a regular diet without difficulty. By post-operative day #8, she was tolerating a regular diet, voiding spontaneously, ambulating independently, and pain was controlled with oral medications. Her Prevena wound vac and JP drain were removed at this time. *) Subsegmental PE She was restarted on therapeutic Lovenox 60 mg BID on post-operative day #3 (___). *) Supraventricular tachycardia *) HTN She was continued on atenolol 25 mg per day with monitoring on telemetry. On ___, she was noted to have sustained tachycardia to the 120s-130s; she was asymptomatic with otherwise stable vital signs and a reassuring exam. An EKG was obtained, by which time she had converted to normal sinus rhythm. Her atenolol was uptitrated to 50 mg per day (her prior home dose) with good effect, and her HR remained stable. *) Rheumatoid arthritis vs SLE There was concern for adrenal insufficiency given Ms. ___ post-operative hypotension. She was treated with stress dose steroids (IV hydrocortisone 50mg Q8H) from ___ and was then transitioned to PO prednisone 7.5mg daily on ___. On post-operative day #8, she was discharged home in stable condition with outpatient follow-up scheduled.
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___ <CHIEF COMPLAINT> abdominal pain <MAJOR SURGICAL OR INVASIVE PROCEDURE> blood transfusions vaginal delivery <HISTORY OF PRESENT ILLNESS> ___ G1P0 at 36w3d with sudden onset severe abdominal pain at 11am this morning. Reports pain is constant. Also reports ?1 episode of LOF, none since. Denies any VB. + nausea. Denies any fevers, chills, substance use, HA, vision changes, RUQ pain. +FM earlier this morning. <PAST MEDICAL HISTORY> OBHx: - G1 GynHx: - denies abnormal Pap, fibroids, Gyn surgery, STIs PMH: denies PSH: denies <SOCIAL HISTORY> ___ <FAMILY HISTORY> non-contributory <PHYSICAL EXAM> Admission: Gen: uncomfortable appearing Abd: rigid, gravid EFW 6# by ___ Ext: no calf tenderness . Discharge: Gen: NAD CV: RRR Resp: breathing comfortably Abd: appropriately tender, soft, non-distended Pelv: minimal lochia Ext: no calf tenderness <PERTINENT RESULTS> Admission labs: ___ 02: 00PM BLOOD WBC-14.7*# RBC-4.41 Hgb-12.5 Hct-38.0 MCV-86 MCH-28.3 MCHC-32.9 RDW-17.2* RDWSD-52.5* Plt ___ ___ 04: 05PM BLOOD WBC-25.9*# RBC-4.27 Hgb-12.2 Hct-37.4 MCV-88 MCH-28.6 MCHC-32.6 RDW-17.4* RDWSD-53.4* Plt ___ ___ 04: 05PM BLOOD Neuts-86.1* Lymphs-6.0* Monos-6.8 Eos-0.1* Baso-0.2 Im ___ AbsNeut-22.41* AbsLymp-1.57 AbsMono-1.78* AbsEos-0.03* AbsBaso-0.04 ___ 02: 00PM BLOOD ___ PTT-27.0 ___ ___ 02: 00PM BLOOD ___ ___ 02: 00PM BLOOD Glucose-103* UreaN-14 Creat-0.8 Na-136 K-3.8 Cl-103 HCO3-20* AnGap-17 ___ 02: 00PM BLOOD ALT-19 AST-46* ___ 02: 00PM BLOOD Calcium-9.1 Phos-2.6* Mg-1.9 UricAcd-5.4 . Pertinent labs: ___ 06: 37PM BLOOD WBC-19.9* RBC-3.18*# Hgb-9.1*# Hct-28.8* MCV-91 MCH-28.6 MCHC-31.6* RDW-17.4* RDWSD-56.7* ___ 10: 33PM BLOOD WBC-22.7* RBC-3.49* Hgb-9.9* Hct-30.2* MCV-87 MCH-28.4 MCHC-32.8 RDW-17.4* RDWSD-53.2* ___ 12: 08AM BLOOD WBC-18.9* RBC-2.94* Hgb-8.5* Hct-25.1* MCV-85 MCH-28.9 MCHC-33.9 RDW-17.2* RDWSD-51.4* Plt Ct-75* ___ 05: 26AM BLOOD WBC-21.1* RBC-2.42* Hgb-6.9* Hct-20.9* MCV-86 MCH-28.5 MCHC-33.0 RDW-17.2* RDWSD-53.8* Plt Ct-52* ___ 08: 30AM BLOOD WBC-19.5* RBC-2.29* Hgb-6.5* Hct-19.7* MCV-86 MCH-28.4 MCHC-33.0 RDW-17.5* RDWSD-53.3* Plt Ct-62* ___ 11: 12PM BLOOD WBC-15.3* RBC-3.47* Hgb-10.0* Hct-29.5* MCV-85 MCH-28.8 MCHC-33.9 RDW-16.6* RDWSD-50.2* Plt Ct-55* ___ 04: 05PM BLOOD ___ PTT-32.8 ___ ___ 10: 33PM BLOOD ___ PTT-29.7 ___ ___ 08: 30AM BLOOD ___ PTT-23.8* ___ ___ 07: 30PM BLOOD ___ PTT-24.7* ___ ___ 04: 05PM BLOOD Fibrino-36*# ___ 06: 37PM BLOOD Fibrino-70*# ___ 10: 33PM BLOOD ___ ___ 12: 08AM BLOOD ___ ___ 02: 49AM BLOOD ___ ___ 08: 30AM BLOOD ___ 07: 30PM BLOOD ___ ___ 06: 37PM BLOOD ALT-19 AST-56* LD(___)-753* TotBili-0.8 DirBili-0.2 IndBili-0.6 ___ 10: 33PM BLOOD ALT-21 AST-59* LD(___)-777* TotBili-0.9 DirBili-0.2 IndBili-0.7 ___ 12: 08AM BLOOD ALT-21 AST-54* LD(___)-705* ___ 06: 37PM BLOOD Hapto-24* ___ 10: 33PM BLOOD Hapto-16* ___ 12: 08AM BLOOD Hapto-<5* . Discharge labs: ___ 09: 38AM BLOOD Plt Ct-78* ___ 09: 38AM BLOOD ___ <MEDICATIONS ON ADMISSION> PNV <DISCHARGE MEDICATIONS> 1. Acetaminophen ___ mg PO Q4H: PRN Pain RX *acetaminophen [Pain Relief] 500 mg 1 capsule(s) by mouth every six (6) hours Disp #*30 Capsule Refills: *0 2. Docusate Sodium 100 mg PO BID: PRN Constipation RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day Disp #*30 Capsule Refills: *0 3. Labetalol 200 mg PO TID RX *labetalol 200 mg 1 tablet(s) by mouth three times a day Disp #*60 Tablet Refills: *1 4. OxycoDONE (Immediate Release) ___ mg PO Q4H: PRN pain RX *oxycodone 5 mg 1 capsule(s) by mouth every six (6) hours Disp #*20 Capsule Refills: *0 <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> s/p vaginal delivery, IUFD, severe pre-eclampsia, DIC, PPH <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Dear Ms. ___, We are so sorry for your loss. Please know that Social Work is available to offer guidance and support if you would like it. Please follow these instructions following discharge from the hospital: Nothing in the vagina for 6 weeks (No sex, douching, tampons) Do not drive while taking Oxycodone Do not take more than 4000mg acetaminophen (APAP) in 24 hrs Do not take more than 2400mg ibuprofen in 24 hrs Please call the on-call doctor at ___ if you develop shortness of breath, dizziness, palpitations, fever of 101 or above, abdominal pain, heavy vaginal bleeding, nausea/vomiting, depression, or any other concerns. Please take your Labetalol as prescribed. This is a medication for your blood pressure. It is important to check your blood pressure at home and to call Dr. ___ with any consistently elevated blood pressures (>160/100).
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Ms. ___ had ultrasound-confirmed ___ fetal demise with no fetal heartbeat on transabdominal ultrasound, along with subjective oligohydramnios, and complete breech with sacrum on maternal right. Sterile vaginal exam was fingertip/80% effaced and the patient underwent induction of labor with misoprostol with vaginal breech delivery. . She had abdominal pain and clinical presentation concerning for abruption. Her vaginal delivery was complicated by disseminated intravascular coagulation and greater than expected blood loss of 700cc likely due to hemolysis and postpartum hemorrhage. She was treated with Pitocin and cytotec as well as 2 doses of cryoprecipitate. She was also given 3 units of packed red blood cells, with stable post transfusion hematocrit. . Ms. ___ was also diagnosed with severe pre-eclampsia by severe range blood pressures. She was treated with 30mg IV labetalol intrapartum, and 24 hours of magnesium IV postpartum. She was started on labetalol 200mg TID postpartum for blood pressure control and was discharged on the same dose. . Ms. ___ was discharged on postpartum day 2, tolerating regular diet, ambulating, pain controlled on oral pain medications, and with outpatient follow up scheduled.
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10966239-DS-10
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> NSAIDS (Non-Steroidal Anti-Inflammatory Drug) / aspirin / Octopus <ATTENDING> ___. <CHIEF COMPLAINT> vaginal bleeding, light-headedness, fatigue <MAJOR SURGICAL OR INVASIVE PROCEDURE> blood transfusion <HISTORY OF PRESENT ILLNESS> HPI: ___ G1P0 with history of right leg DVT and bilateral multiple large pulmonary emboli in ___, recurrent PE in ___ while on Coumadin, now anticoagulated on Xarelto, as well as iron deficiency anemia who presents with light-headedness and fatigue in the setting of heavy vaginal bleeding. She was previously seen in the ED on ___ in the setting of vaginal bleeding at which time she received a blood transfusion and was started on Provera. She reports that her bleeding previously improved, but then she started bleeding heavily again on ___. She reports passing multiple large clots and often changing a pad a day. She then saw Dr. ___ in the office last ___, at which time she got the Depo shot with plan to get Mirena IUD in 2 weeks. She continued to have heavy bleeding until yesterday. Today, her bleeding has significantly improved and she has had minimal bleeding throughout the day. However, she did start to feel increasingly light-headed and fatigued over the past couple days, which brought her to the ED today. She does reports some crampiness, but no severe abdominal pain. No LOC. No CP, SOB, palpitations. Of note, patient had a PUS done ___ that demonstrated the following: 1. The endometrium contains echogenic material likely representing blood products. An anechoic 0.6 cm structure is also seen within the endometrium which may reflect tiny amount of fluid. 2. Fibroid uterus including a 0.8 cm fibroid with submucosal component. 3. Normal ovaries. ROS: negative except as above <PAST MEDICAL HISTORY> GYN HISTORY: LMP: ___ Interval: monthly Length: ___ days Bleeding: heavy bleeding with passage of some clots Cramps: yes PAP SMEAR: (per patient) Date of last PAP: ___ Result: neg Hx of abnormal PAP: denies OB History: G1P0, TAB with D&C <PAST MEDICAL HISTORY> pulmonary embolus RLE DVT Sleep apnea Back pain Headache Iron deficiency anemia Migraines with aura Anxiety Lung nodule (neg CT ___ Surgical History: Roux-en-Y gastric bypass at ___ in ___ <SOCIAL HISTORY> ___ <FAMILY HISTORY> <FAMILY HISTORY> Patient denies family history of cervical, uterine, ovarian, breast or colon cancers. <PHYSICAL EXAM> Discharge physical exam Vitals: stable and within normal limits General: NAD, comfortable CV: RRR, normal s1 and s2, no m/r/g Lungs: normal work of breathing, CTAB Abdomen: obese, soft, non-distended, nontender, no r/g GU: pad with minimal spotting Extremities: no edema, no TTP, pneumoboots in place bilaterally <PERTINENT RESULTS> ___ 01: 30PM BLOOD WBC-7.6 RBC-2.17* Hgb-4.6* Hct-17.2* MCV-79* MCH-21.2* MCHC-26.7* RDW-17.5* RDWSD-50.2* Plt ___ ___ 09: 48PM BLOOD WBC-7.0 RBC-2.52* Hgb-5.8* Hct-20.4* MCV-81* MCH-23.0* MCHC-28.4* RDW-17.8* RDWSD-52.2* Plt ___ ___ 05: 38AM BLOOD WBC-6.1 RBC-2.80* Hgb-6.5* Hct-22.9* MCV-82 MCH-23.2* MCHC-28.4* RDW-17.0* RDWSD-50.7* Plt ___ ___ 07: 35PM BLOOD WBC-7.2 RBC-3.11* Hgb-7.6* Hct-25.1* MCV-81* MCH-24.4* MCHC-30.3* RDW-16.5* RDWSD-47.7* Plt ___ ___ 01: 30PM BLOOD Neuts-75.6* Lymphs-14.5* Monos-8.4 Eos-0.7* Baso-0.1 Im ___ AbsNeut-5.74 AbsLymp-1.10* AbsMono-0.64 AbsEos-0.05 AbsBaso-0.01 ___ 01: 36PM BLOOD ___ PTT-28.0 ___ ___ 05: 38AM BLOOD ___ PTT-30.4 ___ ___ 05: 38AM BLOOD ___ 01: 30PM BLOOD Glucose-91 UreaN-13 Creat-0.6 Na-137 K-4.2 Cl-106 HCO3-18* AnGap-13 ___ 01: 30PM BLOOD Calcium-8.2* Phos-3.2 Mg-1.8 ___ 09: 55PM BLOOD Hgb-6.3* calcHCT-19 <MEDICATIONS ON ADMISSION> Medications - Prescription ACETAZOLAMIDE - acetazolamide ER 500 mg capsule,extended release. 2 capsule(s) by mouth twice a day week 1: 500mg qAM / 1,000mg qPM week 2: 1,000mg BID FLUTICASONE PROPIONATE - fluticasone propionate 50 mcg/actuation nasal spray,suspension. ___ sprays intranasally once per day FLUTICASONE PROPIONATE - fluticasone propionate 50 mcg/actuation nasal spray,suspension. 1 spray intranasal each nostril once a day GABAPENTIN - gabapentin 300 mg capsule. 1 capsule(s) by mouth three times a day 1 tab before bed x 5days, then increase to 2x/day for 5 days, then increase to 3x/day LORAZEPAM - lorazepam 0.5 mg tablet. 1 tablet(s) by mouth once a day as needed for anxiety or panic attack MEDROXYPROGESTERONE - medroxyprogesterone 150 mg/mL intramuscular syringe. 1 syringe IM every 3 months OMEPRAZOLE - omeprazole 20 mg capsule,delayed release. 1 capsule(s) by mouth qam RIVAROXABAN [XARELTO] - Xarelto 20 mg tablet. 1 tablet(s) by mouth once a day ZOLMITRIPTAN - zolmitriptan 5 mg tablet. 1 tablet(s) by mouth as needed as needed for migraine may repeat dose in 2 hrs, max 2 tabs per day - (Not Taking as Prescribed: not taking as prescribed) Medications - OTC CHOLECALCIFEROL (VITAMIN D3) - cholecalciferol (vitamin D3) 1,000 unit capsule. 1 capsule(s) by mouth once a day CYANOCOBALAMIN (VITAMIN B-12) - cyanocobalamin (vit B-12) 1,000 mcg tablet. 1 tablet(s) by mouth once a day FERROUS GLUCONATE - ferrous gluconate 324 mg (36 mg iron) tablet. 1 tablet(s) by mouth once a day MAGNESIUM - magnesium 200 mg tablet. 2 tablet(s) by mouth daily start 1 tab daily for 1 week, then 2 tabs daily for migraine MAGNESIUM OXIDE - magnesium oxide 400 mg capsule. 1 capsule(s) by mouth daily MULTIVITAMIN - multivitamin tablet. 1 tablet(s) by mouth once a day RIBOFLAVIN (VITAMIN B2) - riboflavin (vitamin B2) 400 mg tablet. 1 tablet(s) by mouth once a day <DISCHARGE MEDICATIONS> 1. Fluticasone Propionate 110mcg 2 PUFF IH BID 2. Omeprazole 20 mg PO DAILY 3. Rivaroxaban 20 mg PO DAILY <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> acute blood loss anemia <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Dear Ms. ___, You were admitted to the gynecology service for management of your symptomatic anemia due to heavy vaginal bleeding. You were transfused 4 units of packed red blood cells, and your blood counts have risen appropriately. 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: * Continue to take your Xarelto as prescribed. * Please call your GYN provider if you have heavy vaginal bleeding. * You may eat a regular diet. * You may walk up and down stairs. Call your doctor for: * vaginal bleeding requiring >1 pad/hr * anemia symptoms including dizziness, lightheadedness, palpitations, shortness of breath 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 ___ G1P0 with h/o R leg DVT and b/l multiple large PEs in ___, recurrent PE in ___ while on Coumadin, now anticoagulated on Xarelto, as well as iron deficiency anemia admitted with symptomatic anemia in the setting of heavy vaginal bleeding. On ___, Ms. ___ was admitted to the gynecology service for observation due to heavy vaginal bleeding in the setting of anticoagulation. She was hemodynamically stable though presented with lightheadedness and fatigue. Her Hct was 17 on admission. She was transfused 2 units of packed red blood cells with a rise in her Hct to 20.4. She was therefore transfused 2 additional units of packed red blood cells with an appropriate rise in her Hct to 25.1. She was continued on her home dose of Xarelto throughout her admission. On ___, she was discharged in stable condition with outpatient follow up scheduled for progesterone-secreting IUD placement and endometrial biopsy.
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10968610-DS-11
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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 <MAJOR SURGICAL OR INVASIVE PROCEDURE> primary low transverse cesarean section <HISTORY OF PRESENT ILLNESS> Ms. ___ is ___ yo G3P1 at 33.0 weeks who presents with leakage of clear fluid this evening. The patient was in the bathroom bathing her young son when she noted fluid dripping down her leg. She urinated and the fluid kept dripping. Continues to leak fluid. She reports active fetal movement. Denies abdominal pain, cramping, or contractions. No vaginal bleeding. Feels well. No fever, chills, nausea/vomiting. <PAST MEDICAL HISTORY> PRENATAL COURSE (1)EDC ___ by IVF dating (2)O+/Ab neg, GLT nl, (3)U/S: nl FFS (4)IVF pregnancy PAST OBSTETRIC HISTORY 1 SVD 8#, Term, no complications 1 chemical pregnancy PAST GYNECOLOGIC HISTORY - denies GC/CT/Herpes - infertility PAST MEDICAL HISTORY denies PAST SURGICAL HISTORY denies <SOCIAL HISTORY> ___ <FAMILY HISTORY> non-contributory <PHYSICAL EXAM> VITALS: T 97.3, BP 122/82, HR 100, RR 12 GENERAL: well, NAD ABDOMEN: gravid, soft, non-tender, no fundal tenderness SVE: deferred SSE: per Dr. ___: gross clear fluid. Os closed/long appearing TOCO: q 20 for 2 CTX. 3 total CTX over 2 hours tracing FHR: 135 + accels, no decels, mod variability TAUS: AFI 10.3, Breech, ___ BPP <PERTINENT RESULTS> ___ WBC-7.6 Hgb-11.1 Hct-32.0 Plt ___ ___ WBC-7.0 Hgb-11.3 Hct-33.0 Plt ___ ___ WBC-6.7 Hgb-11.4 Hct-31.8 Plt ___ ___ URINE Blood-TR Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-MOD ___ URINE Blood-TR Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG URINE CULTURE (Final ___: NO GROWTH. <MEDICATIONS ON ADMISSION> prenatal vitamins <DISCHARGE MEDICATIONS> 1. hospital grade breast Pump baby in NICU 2. APNO apply after nursing as needed 3. Motrin 600 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for pain. Disp: *60 Tablet(s)* Refills: *0* 4. Percocet ___ mg Tablet Sig: ___ Tablets PO every ___ hours as needed for pain. Disp: *40 Tablet(s)* Refills: *0* <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> s/p c/section <DISCHARGE CONDITION> stable <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> see discharge instructions
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___ yo G3P1 IVF pregnancy admitted at 33w0d with PPROM. . *) PPROM: Pt showed no evidence of infection while admitted. She was afebrile and without fundal tenderness. She was treated with Ampicillin and Erythromycin for seven days for latency. She was delivered on ___ at 34w0d by primary cesarean section given the breech presentation. Please see operative report for details. . *) FWB: Fetal testing was reassuring during admission. A course of betamethasone was given for prematurity and the NICU was consulted. Liveborn female infant delivered from breech, weight unknown at the time of delivery, apgars of 8 and 8. NICU staff was in attendance for delivery and transferred the infant for prematurity. . Pt's post-partum course was uncomplicated and she was discharged home POD#4 in good condition.
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10969274-DS-9
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Metformin <ATTENDING> ___ ___ Complaint: abdominal pain <MAJOR SURGICAL OR INVASIVE PROCEDURE> D&C <HISTORY OF PRESENT ILLNESS> ___ yo G2P0 at ___ by ___ transferred from ___ due to abdominal pain. She reports a history of several days of increasing spotting, along with cramping and lower abdominal/pelvic pain for the past day or two. The pregnancy is unexpected, and she is ambivalent about it. At ___, ultrasound showed a gestational sac but the ovaries were unable to be visualized. She was transferred to the ___ ED for further evaluation, due to the concern for torsion, ectopic, or another acute process. In the ED, she has received a total of 8mg IV morphine and 1mg IV Ativan. On initial evaluation, she reported strong lower abdominal cramping pain radiating to her back, equal bilaterally. The pain is not associated with nausea or vomiting, although she does report intermittent N/V for the past few weeks. She has also had some loose stools for the past week. Otherwise, she denies fevers, chills, dysuria, other associated symptoms. After the second dose of 4mg IV morphine, she reported feeling much better. When asked whether this pain feels similar to her prior SAB, she states "oh, ___, but it passed more quickly before, once the bleeding started." <PAST MEDICAL HISTORY> OBHx: G2P0 - SAB x 1 GynHx: - LMP ___ - denies h/o STIs, abnormal Paps, cysts, fibroids MedHx: - T2DM, poorly controlled per her report, ___ 200's usually - h/o nephrolithiasis SurgHx: - stents ___ nephrolithiasis - right leg surgery - tympanostomy tubes <SOCIAL HISTORY> ___ <FAMILY HISTORY> non-contributory <PHYSICAL EXAM> (on admission) Vitals: T 97.4, BP 122/71, HR 91, RR 20, O2sat: 97% RA, ___ 197 GENERAL: NAD, resting comfortably CV: RRR Lungs: CTAB ABDOMEN: soft, obese, mild diffuse lower quadrant TTP, no rebound/guarding SSE: small amount of blood in the vaginal vault, unable to visualize cervix well due to positioning, habitus BME: initially with TTP when cervix touched (not moved), then intermittently with moderate adnexal TTP, at times right, at times left, then no CMT, unable to assess uterus/adnexa for masses or size due to body habitus, diffuse discomfort with exam Imaging: TVUS - intrauterine gestational sac is identified though, size < dates and no fetal pole is identified, ovaries not visualized, no free fluid <PERTINENT RESULTS> ___ WBC-10.9 RBC-4.77 Hgb-14.5 Hct-40.6 MCV-85 Plt-310 ___ Neuts-61.7 ___ Monos-2.4 Eos-1.6 Baso-1.1 ___ Glucose-255 BUN-8 Cre-0.6 Na-137 K-4.0 Cl-103 HCO3-20 ___ Calcium-9.8 Phos-4.0 Mg-1.4 ___ %HbA1c-10.3 eAG-249 ___ URINE Blood-LG Nitrite-NEG Protein-150 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG ___ URINE ___ Bacteri-MOD Yeast-NONE ___ URINE CULTURE (Final ___: BETA STREPTOCOCCUS GROUP B. ~5000/ML <MEDICATIONS ON ADMISSION> Actos glyburide <DISCHARGE MEDICATIONS> Actos glyburide <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> Vaginal Bleeding <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> You had a D&C procedure. Please call for heavy vaginal bleeding, severe abdominal pain, fevers, chills, nausea, vomiting, or any other concerning symptoms. Please keep all of your follow up appointments as directed.
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___ y/o G2P0 admitted for further workup of her abdominal pain. She was afebrile and without any evidence of infection. Pelvic ultrasound confirmed a 5w4d fetal pole and a yolk sac, with no heartbeat (not consistent with her LMP). The ovaries were not visualized. Given her continued abdominal pain requiring narcotics, an MRI was obtained and revealed a fatty liver, otherwise normal study. . In regards to her poorly controlled diabetes, she was continued on her home meds. Her hemoglobin A1C was elevated (10.3%) and she was counseled regarding the implications of poor glucose control in pregnancy. Also discussed with her the implications of poor glucose control with increased risk of pregnancy complications including SAB, IUFD, fetal cardiac defects. After discussion the patient elected to undergo termination of undesired pregnancy. At the time of surgery she was noted to be bleeding with a likely threatened abortion. Additionally the patient desires contraception. We discussed all methods of contraception and the patient elects Mirena IUD insertion at the time of her D&C. Consent form is signed for both of these procedures. Her procedures were uncomplicated. She was discharged home on hospital day 0 in good condition with gyn follow up.
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10971078-DS-20
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> Probably metastatic ovarian cancer <MAJOR SURGICAL OR INVASIVE PROCEDURE> diagnostic laparoscopy, ex-lap, modified radical TAH, BSO, omentectomy, low anterior resection with primary anastomosis, right hemicolectomy and terminal ileum resection, right diaphragm stripping, full thickness diaphragm resection and repair with chest tube placement, left pelvic lymph node sampling <HISTORY OF PRESENT ILLNESS> Mrs. ___ is a pleasant ___ G2P2 ___ female who presented to an outside hospital complaining of abdominal distention. CT imaging of the abdomen and pelvis noted complex solid and cystic pelvic mass as well as extensive peritoneal carcinomatosis and larger peritoneal based masses scattered throughout the abdomen and pelvis. Tumor markers including CEA, ___, Ca125 were drawn and sent. CA125 and ___ were both elevated. CEA was normal at 1.5. CA125 was > 9000 (normal <35) and ___ is 96 (normal range ___. Recent pap smear on ___ normal, HPV negative. Ms. ___ reports that her symptoms began in ___. Prior to that she had been in her usual state of health. She reports that she developed heartburn and upper abdominal pain and fwas ultimately started on heartburn medication that did not relieve her symptoms. When symptoms did not improve she was referred to gastroenterology and ultimately underwent endoscopy and colonoscopy which were both normal. Symptoms continue to persist. She states that she had approximately 15 pound weight loss since ___ and ultimately with ongoing symptoms her primary care provider recommended ___ CT scan of the abdomen and pelvis. This noted the above findings and prompted a referral to GYN oncology. In addition to indigestion and left upper quadrant pain the patient reports diarrhea with every meal. She reports pain in her lower abdomen and pelvis. She denies postmenopausal bleeding. She denies urinary symptoms. She does report blood in her stool. She reports itching around her anus. She also states that she has had itching on her body since ___. She believes that she has a fungus on her skin and is worried that by sucking her thumb at nighttime she may have caused her ovarian cancer. She also is worried that the fungus is crawling underneath her skin and eating her body from the inside out. She denies having any other visual hallucinations. She has had skin rash off and on since ___. <PAST MEDICAL HISTORY> Gynecologic history: Menarche at age ___. Menopause at age ___. Denies use of birth control or hormone replacement therapy. Preventative healthcare: Colonoscopy ___ Mammogram ___ Bone mineral density study never Last visit with PCP ___ PMH: Pelvic mass. Carcinomatosis. Elevated CA125. Sinusitis. <SOCIAL HISTORY> ___ <FAMILY HISTORY> Cousin and maternal aunt with ovarian cancer. Denies breast cancer, uterine cancer, cervical cancer, and colon cancer. Sister: diabetes, hypertension. Uncertain if anyone has undergone genetic testing. <PHYSICAL EXAM> On day of discharge: 24 HR Data (last updated ___ @ 344) Temp: 99.0 (Tm 99.0), BP: 145/81 (121-149/79-82), HR: 76 (75-90), RR: 24 (___), O2 sat: 95% (95-96), O2 delivery: RA Fluid Balance (last updated ___ @ 2155) Last 8 hours No data found Last 24 hours Total cumulative -165ml IN: Total 1160ml, PO Amt 1160ml OUT: Total 1325ml, Urine Amt 1325ml General: NAD, comfortable appearing. Neuro: AxO x 3, affect appropriate. HEENT: Normocephalic, atraumatic. Sclerae anicteric. Cardiovascular: RRR, no rubs/murmurs/gallops. Pulmonary: normal rate and work of breathing, Lungs CTAB Abdomen: normoactive bowel sounds. Soft, mildly tender to palpation, nondistended. No rebound/guarding. Incisions c/d/I GU: no pad, no foley MSK: Lower extremities without edema, erythema, or TTP. TEDs in place. <PERTINENT RESULTS> ADMISSION LABS ___ 06: 40AM BLOOD WBC-6.9 RBC-4.37 Hgb-9.5* Hct-32.6* MCV-75* MCH-21.7* MCHC-29.1* RDW-18.6* RDWSD-50.7* Plt ___ ___ 06: 15AM BLOOD WBC-8.1 RBC-3.44* Hgb-7.4* Hct-26.3* MCV-77* MCH-21.5* MCHC-28.1* RDW-18.9* RDWSD-51.8* Plt ___ ___ 06: 00PM BLOOD Glucose-187* UreaN-13 Creat-1.0 Na-141 K-5.3 Cl-108 HCO3-19* AnGap-14 DISCHARGE LABS ___ 07: 00AM BLOOD WBC-9.4 RBC-3.76* Hgb-8.9* Hct-28.7* MCV-76* MCH-23.7* MCHC-31.0* RDW-19.5* RDWSD-53.5* Plt ___ ___ 07: 00AM BLOOD Glucose-90 UreaN-8 Creat-0.6 Na-141 K-3.4* Cl-101 HCO3-27 AnGap-___/A/P (___): 1. New pneumomediastinum and pneumopericardium. This is likely postsurgical. No discrete evidence of hemodynamic compromise however this would be better evaluated with echocardiography if this is a clinical concern. 2. No pulmonary embolism or acute aortic injury. 3. Status post TAH/BSO, tumor debulking and partial bladder resection with small intraperitoneal free air may be related to recent surgery. 4. Focal thickening along the mid to distal descending colon and upper sigmoid colon at the site of recently resected metastatic disease is likely postsurgical, however could reflect persistent tumor burden versus postsurgical inflammation versus a small hematoma along the intestinal wall. Contrast passes distally to this finding to the rectum. 5. Focal enhancement of the left lower quadrant peritoneum, however given recent tumor debulking this could reflect postsurgical changes. Infection is not completely excluded in the appropriate clinical context. 6. Right lower quadrant and upper pelvic surgical anastomosis appear intact without discrete evidence of extraluminal contrast to indicate leak. 7. The right lower pelvic anastomosis appears intact. There is luminal irregularity without frank extravasated contrast to suggest perforation. 8. Asymmetric wall thickening and edema of the descending colon and rectum, which may be postsurgical, however proctocolitis is not excluded. Clinical correlation is recommended. 9. Some distention of small bowel which could reflect a mild ileus. No dilated small bowel or air-fluid levels to indicate acute obstruction. 10. No substantial change in size of several bilateral pulmonary nodules, measuring up to 5 mm. Recommend close attention on follow-up. 11. 3 mm hypodensity along the uncinate process of the pancreas which suggests a small IPMN. 12. Stable size of a nodular soft tissue density lesion along the medial spleen consistent with likely metastatic disease. PATHOLOGY Cytology: positive for malignant cells consistent with serous carcinoma Pathology of surgical specimens: pending <MEDICATIONS ON ADMISSION> None <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. Docusate Sodium 100 mg PO BID Hold for loose stools RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day Disp #*60 Capsule Refills: *0 3. Enoxaparin Sodium 40 mg SC DAILY RX *enoxaparin 40 mg/0.4 mL 1 syringe subcutaneously Once daily Disp #*28 Syringe Refills: *0 4. Famotidine 20 mg PO BID RX *famotidine 20 mg 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills: *0 5. Ibuprofen 600 mg PO Q6H: PRN Pain - Mild Take with food. Do not exceed 2400mg in 24 hrs RX *ibuprofen 600 mg 1 tablet(s) by mouth every six (6) hours Disp #*50 Tablet Refills: *1 6. OxyCODONE (Immediate Release) 5 mg PO Q4H: PRN Pain - Moderate Reason for PRN duplicate override: Alternating agents for similar severity ___ cause sedation. Do not drink or drive. RX *oxycodone 5 mg 1 tablet(s) by mouth every four (4) hours Disp #*25 Tablet Refills: *0 7. Psyllium Wafer ___ WAF PO DAILY <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> Ovarian Cancer, postoperative ileus <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Dear Ms. ___, You were admitted to the gynecologic oncology service after undergoing the procedures listed below. You have recovered well after your operation, and the team feels that you are safe to be discharged home. Please follow these instructions: Abdominal instructions: * Your staples will be removed within 2 weeks from your surgery. This appointment should already been scheduled for you. Please call if you do not have an appointment scheduled. * Take your medications as prescribed. We recommend you take non-narcotics (i.e. Tylenol, ibuprofen) regularly for the first few days post-operatively, and use the narcotic as needed. As you start to feel better and need less medication, you should decrease/stop the narcotic first. * Take a stool softener to prevent constipation. You were prescribed Colace. If you continue to feel constipated and have not had a bowel movement within 48hrs of leaving the hospital you can take a gentle laxative such as milk of magnesium. * Do not drive while taking narcotics. * Do not combine narcotic and sedative medications or alcohol. * Do not take more than 4000mg acetaminophen (tylenol) in 24 hrs. * No strenuous activity until your post-op appointment. * Nothing in the vagina (no tampons, no douching, no sex) for 12 weeks. * No heavy lifting of objects >10 lbs for 6 weeks. * You may eat a regular diet. * It is safe to walk up stairs. Incision care: * You may shower and allow soapy water to run over incision; no scrubbing of incision. No bath tubs for 6 weeks. * You should remove your port site dressings ___ days after your surgery, if they have not already been removed in the hospital. Leave your steri-strips on. If they are still on after ___ days from surgery, you may remove them. * If you have staples, they will be removed at your follow-up visit. Constipation: * Drink ___ liters of water every day. * Incorporate 20 to 35 grams of fiber into your daily diet to maintain normal bowel function. Examples of high fiber foods include: Whole grain breads, Bran cereal, Prune juice, Fresh fruits and vegetables, Dried fruits such as dried apricots and prunes, Legumes, Nuts/seeds. * Take Colace stool softener ___ times daily. * Use Dulcolax suppository daily as needed. * Take Miralax laxative powder daily as needed. * Stop constipation medications if you are having loose stools or diarrhea. To reach medical records to get the records from this hospitalization sent to your doctor at home, call ___. 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 Lovenox injections: * Patients having surgery for cancer have risk of developing blood clots after surgery. This risk is highest in the first four weeks after surgery. You will be discharged with a daily Lovenox (blood thinning) medication. This is a preventive dose of medication to decrease your risk of a forming a blood clot. A visiting nurse ___ assist you in administering these injections.
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Ms. ___ is a ___ year old woman who was admitted to the gynecologic oncology service after undergoing diagnostic laparoscopy, exploratory laparotomy, modified radical total abdominal hysterectomy, bilateral salpingo-oophorectomy, omentectomy, low anterior resection with primary anastomosis, right hemicolectomy and terminal ileum resection, right diaphragm stripping, full thickness diaphragm resection and repair with chest tube placement, left pelvic lymph node sampling, and cystoscopy. Please see the operative report for full details. Her post-operative course is detailed as follows. Immediately postoperatively, her pain was controlled with a combined epidural. A CXR confirmed correct placement of the chest tube which was placed on low continuous suction. On POD#1, a CXR confirmed showed no pneumothorax and output from the tube <150cc mL over 24hrs. It was placed to water seal, and subsequently removed on POD#2. On POD#2, she developed a fever to Tmax 101.4 F attributed to post-operative inflammatory response. There was no other signs concerning for acute infection or thromboembolic pathology. The same day, she was transfused 2u pRBCs for a Hct of 23.3 without evidence of ongoing bleeding. She was transitioned to a liquid diet and oral pain medications on POD#3. The epidural and foley catheter were removed. On POD#4, she had episodes of emesis and nausea, and an abdominal x-ray showed dilated small bowel loops concerning for ileus. She was made NPO with IV fluids. Over the course of the next 6 days, her diet was gradually advanced back to regular. On POD#6, she also had an episode of tachycardia and chest discomfort. EKG was sinus rhythm. CTA was negative for pulmonary embolism. A CT of the abdomen and pelvis showed no evidence of intestinal perforation or obstruction. By post-operative day ___, she was tolerating a regular diet, voiding spontaneously, ambulating independently, and pain was controlled with oral medications. She was then discharged home in stable condition with outpatient follow-up scheduled.
| 2,885
| 458
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10971078-DS-21
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> diarrhea <MAJOR SURGICAL OR INVASIVE PROCEDURE> none <HISTORY OF PRESENT ILLNESS> ___ s/p optimal cytoreductive surgery ex-lap modified radical hysterectomy, bilateral salpingo-oophorectomy, low anterior resection, right hemicolectomy, appendectomy, diaphragm stripping, omentectomy, pelvic lymph node dissection, ureteral lysis, and bladder peritonectomy on ___ for FIGO stage 4B metastatic high grade serous ovarian carcinoma. Today she presented at clinic for a wound check. The wound had noted to be healing appropriately w/o drainage, however, patient endorsed Q1H non-bloody diarrhea as well as decrease PO intake and weakness since discharged from the hospital on ___. At this time she denies nausea, had 1 episode of emesis last night but none since. She states she has very little appetite and has mostly done a soft-food diet since being home. She endorses 10 lbs weight loss in the past 2 weeks. Denies fevers, endorses intermittent chills, malaise, generalized weakness, fatigue, as lower abdominal crampy pain L>R. She endorses sore throat. She denies any VB or D/C, pelvic pain, SOB, CP, palpitations, urinary symptoms. Of note, she missed her appointment with Dr. ___ onc) yesterday because she was at the ___ office. ROS: 10 point review of symptoms negative except as noted above <PAST MEDICAL HISTORY> Oncological history: Work-Up: ___: patient began having symptom of indigestion, vague abdominal pain and 19 lbs weight-loss, diarrhea w/ every meal ___: CT abdomen/pelvis at CHA showed complex solid and cystic pelvic mass and extensive peritoneal carcinomatosis and large peritoneal based masses throughout abdomen/pelvis. CEA1.5, ___, CA125 >9000 ___: 7mm subpleural left apical pulmonary nodule c/f metastatic disease, metastaatic serosal deposing in spleen and liver. eccentric wall thickening on stomach c/f metastasis. R epicardial lymph node ___: ex-lap modified radical hysterectomy, bilateral salpingo-oophorectomy, low anterior resection, right hemicolectomy, appendectomy, diaphragm stripping, omentectomy, pelvic lymph node dissection, ureteral lysis, and bladder peritonectomy and chest tube placement ___: chest ube placement on low continuous suction, removed on POD2, fever (self resolved), 2u pRBCs transfused. Ileus x 3 days, tachycardia that self-resolved, CT ___ w/ no evidence of perforation or obstruction. ___: CT abd/pel showed new peneumomediastinu, and peumopericardium, no evidence of hymodynamic compromise, no PE, focal thickening along mid-distal descending colon that could represent persistent tumor burden, hematoma, post-surgical. Focal enhancement to the LLQ, infxn not excluded. Asymmetric wall thickening and edema of the descending colon and rectum, which may be postsurgical, however proctocolitis is not excluded. Final pathology showed FIGO stage 4B metastatic high grade serous ovarian carcinoma involving the uterus, bilateral ovaries, omentum, falciform, right diaphragm, Gerota's fascia, colon, external iliac lymph nodes, anterior abdominal wall, and peritoneum. Staining was positive for ER, WT1 and p16, with aberrant "null" p53 expression. Gynecologic history: Menarche at age ___. Menopause at age ___. Denies use of birth control or hormone replacement therapy. PMH: FIGO stage 4B metastatic high grade serous ovarian carcinoma <SOCIAL HISTORY> ___ <FAMILY HISTORY> Cousin and maternal aunt with ovarian cancer. Denies breast cancer, uterine cancer, cervical cancer, and colon cancer. Sister: diabetes, hypertension. Uncertain if anyone has undergone genetic testing. <PHYSICAL EXAM> PHYSICAL EXAM ON ADMISSION: ___ 1525 Temp: 98.3 PO BP: 108/70 L Sitting HR: 86 RR: 18 O2 sat: 97% O2 delivery: RA Gen: A&O, NAD, weak HEENT: dry mucosa, mild scleral icterus CV: RRR Resp: CTAB Abd: +BS, soft, midly tender LLQ> RLQ w/ deep palpation, no rebound or guarding Incision: midline lapartomy clean/intact/ and dry except for a 2cm w/ packing in place. No signs of erythema or induration Ext: calves nontender bilaterally, no c/c/e ---- PHYSICAL EXAM ON DAY OF DISCHARGE: On day of discharge: Afebrile, vitals stable General: NAD, comfortable CV: RRR Lungs: CTAB Abdomen: soft, non-distended, non-tender to palpation without rebound or guarding, midline vertical incision w/ two areas of wound separation (1cm near umbilicus, punctate separation near pubic symphysis) packed without excessive drainage or erythema. Extremities: no edema, no TTP <PERTINENT RESULTS> ___ 07: 35AM BLOOD WBC-10.4* RBC-3.45* Hgb-8.0* Hct-26.8* MCV-78* MCH-23.2* MCHC-29.9* RDW-19.6* RDWSD-54.4* Plt ___ ___ 08: 00AM BLOOD WBC-10.4* RBC-3.43* Hgb-7.8* Hct-26.4* MCV-77* MCH-22.7* MCHC-29.5* RDW-19.2* RDWSD-53.7* Plt ___ ___ 12: 52PM BLOOD WBC-12.3* RBC-3.68* Hgb-8.4* Hct-29.3* MCV-80* MCH-22.8* MCHC-28.7* RDW-19.9* RDWSD-56.8* Plt ___ ___ 08: 00AM BLOOD Neuts-70.2 Lymphs-18.2* Monos-7.1 Eos-2.6 Baso-0.4 Im ___ AbsNeut-7.31* AbsLymp-1.89 AbsMono-0.74 AbsEos-0.27 AbsBaso-0.04 ___ 12: 52PM BLOOD Neuts-76.3* Lymphs-14.7* Monos-5.5 Eos-1.6 Baso-0.4 Im ___ AbsNeut-9.37* AbsLymp-1.81 AbsMono-0.68 AbsEos-0.20 AbsBaso-0.05 ___ 07: 35AM BLOOD Glucose-101* UreaN-5* Creat-0.7 Na-140 K-4.0 Cl-103 HCO3-26 AnGap-11 ___ 08: 00AM BLOOD Glucose-102* UreaN-8 Creat-0.7 Na-138 K-3.6 Cl-101 HCO3-24 AnGap-13 ___ 12: 52PM BLOOD Glucose-98 ___ 12: 52PM BLOOD UreaN-14 Creat-0.8 Na-140 K-4.0 Cl-99 HCO3-23 AnGap-18 ___ 12: 52PM BLOOD ALT-11 AST-9 AlkPhos-107* ___ 12: 52PM BLOOD Lipase-95* ___ 07: 35AM BLOOD Calcium-8.8 Phos-3.8 Mg-2.0 ___ 08: 00AM BLOOD Calcium-8.5 Phos-3.7 Mg-2.0 ___ 12: 52PM BLOOD Albumin-3.2* Calcium-9.0 Phos-4.7* Mg-2.2 ___ 07: 42PM BLOOD Lactate-0.7 ___ 01: 00PM STOOL CDIFPCR-POS* CDIFTOX-NEG ___ 05: 10PM STOOL VoidSpe-C.DIFF <MEDICATIONS ON ADMISSION> 1. Acetaminophen 2. lovenox 3. ibuprofen 4. colace <DISCHARGE MEDICATIONS> 1. Ensure Enlive (food supplemt, lactose-reduced) 0.08 gram-1.5 kcal/mL oral TID Nutrition supplement RX *food supplemt, lactose-reduced [Ensure Enlive] 0.08 gram-1.5 kcal/mL 1 ml by mouth three times a day Refills: *1 2. Hydrocortisone (Rectal) 2.5% Cream ___ID Apply twice a day for no more than 2 weeks RX *hydrocorTISone 1 (s) rectally BID/PRN Disp #*1 Applicator Refills: *0 3. Multivitamins 1 TAB PO DAILY RX *multivitamin 1 capsule(s) by mouth once a day Disp #*30 Tablet Refills: *3 4. Vancomycin Oral Liquid ___ mg PO Q6H Duration: 10 Days RX *vancomycin 125 mg 1 capsule(s) by mouth every six (6) hours Disp #*36 Capsule Refills: *0 <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> c.diff colitis <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Dear Ms. ___, You were admitted to the gynecologic oncology service with persistent diarrhea. You were given IV fluids and you were able to tolerate diet and the team feels that you are safe to be discharged home. Please follow these instructions: Abdominal instructions: * Your staples will be removed within 2 weeks from your surgery. This appointment should already been scheduled for you. Please call if you do not have an appointment scheduled. * Take your medications as prescribed. We recommend you take non-narcotics (i.e. Tylenol, ibuprofen) regularly for the first few days post-operatively, and use the narcotic as needed. As you start to feel better and need less medication, you should decrease/stop the narcotic first. * Take a stool softener to prevent constipation. You were prescribed Colace. If you continue to feel constipated and have not had a bowel movement within 48hrs of leaving the hospital you can take a gentle laxative such as milk of magnesium. * Do not drive while taking narcotics. * Do not combine narcotic and sedative medications or alcohol. * Do not take more than 4000mg acetaminophen (tylenol) in 24 hrs. * No strenuous activity until your post-op appointment. * Nothing in the vagina (no tampons, no douching, no sex) for 12 weeks. * No heavy lifting of objects >10 lbs for 6 weeks. * You may eat a regular diet. * It is safe to walk up stairs. Incision care: * You may shower and allow soapy water to run over incision; no scrubbing of incision. No bath tubs for 6 weeks. 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 only if constipated. * 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 Lovenox injections: * Patients having surgery for cancer have risk of developing blood clots after surgery. This risk is highest in the first four weeks after surgery. You will be discharged with a daily Lovenox (blood thinning) medication. This is a preventive dose of medication to decrease your risk of a forming a blood clot. A visiting nurse ___ assist you in administering these injections.
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Ms. ___ was admitted to the gyn/onc service with persistent diarrhea, later found to have c.diff colitis with negative toxin. She was given IV hydration and started on PO vancomycin. Given her 11% weightloss over the last month, nutrition was consulted and she was started on a TID ensure regimen and multivitamin supplementation. Of note, she had a known wound separation without evidence of infection which was managed by wound care. On hospital day #3, she was tolerating a regular diet. She had improvement of her diarrhea. She was discharged home in stable condition with nutrition supplementation, vancomycin, and appropriate follow-up scheduled.
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| 135
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10973254-DS-9
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> ___ <ATTENDING> ___. <CHIEF COMPLAINT> elevated blood pressure <MAJOR SURGICAL OR INVASIVE PROCEDURE> Cesarean delivery <HISTORY OF PRESENT ILLNESS> ___ G1 at 35+2 sent from clinic for pre-eclampsia eval. Seen today for antenatal testing given low ___ and borderline IUGR. Ultrasound today showed oligohydramnios with AFI 3.62cm, BPP ___ (minus 2 for fluid). She was given her first dose of betamethasone for preterm oligohydramnios and was found to have a BP of 151/96 and 147/97 on repeat. She denies HA, vision changes, RUQ pain, contractions, vaginal bleeding, or leaking fluid. <PAST MEDICAL HISTORY> PNC: ___ ___ by U/S Labs: B+/Ab-/RPRnr/RI/HbsAg-/HIV-/GBSunk Screening LR ___, low ___ FFS wnl, female, ant placenta GLT wnl U/S: - ___ EFW 1808g ___, intermittently elevated dopplers, no absent or reversed diastolic flow - ___ cephalic AFI 3.62cm, MVP 1.86cm, BPP ___ fluid Issues: - low ___: serial growth scans, most recent scan as above - carpal tunnel: wrist splints - anemia: on iron daily ObHx: G1 current GYNHx: denies h/o abnormal paps, fibroids, cysts. Remote history of chlamydia ___, negative in pregnancy PMH: heart murmur, nl echo ___, asthma (no hospitalizations) PSH: <SOCIAL HISTORY> ___ <FAMILY HISTORY> non contributory <PHYSICAL EXAM> Discharge physical exam: Gen: NAD CV: RRR P: No respiratory distress on RA Abd: soft, appropriately TTP, fundus firm below the umbilicus, incision c/d/i Ext: WWP <PERTINENT RESULTS> ___ 11: 24AM CREAT-0.8 ___ 11: 24AM ALT(SGPT)-26 AST(SGOT)-26 ___ 11: 24AM URIC ACID-7.0* ___ 11: 24AM URINE HOURS-RANDOM CREAT-33 TOT PROT-22 PROT/CREA-0.7* ___ 11: 24AM WBC-7.6 RBC-3.79* HGB-10.9* HCT-35.1 MCV-93 MCH-28.8 MCHC-31.1* RDW-15.7* RDWSD-52.9* ___ 11: 24AM PLT COUNT-260 ___ 11: 24AM URINE COLOR-Straw APPEAR-Clear SP ___ ___ 11: 24AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 LEUK-NEG ___ 11: 24AM URINE RBC-0 WBC-<1 BACTERIA-FEW YEAST-NONE EPI-<1 <MEDICATIONS ON ADMISSION> albuterol, ranitidine, loratadine, PNV <DISCHARGE MEDICATIONS> 1. Docusate Sodium 100 mg PO BID: PRN Constipation RX *docusate sodium 100 mg 1 tablet(s) by mouth twice a day Disp #*30 Tablet Refills: *0 2. Ibuprofen 600 mg PO Q6H: PRN Pain RX *ibuprofen 600 mg 1 tablet(s) by mouth q6hr Disp #*30 Tablet Refills: *0 3. Labetalol 200 mg PO BID RX *labetalol 200 mg 1 tablet(s) by mouth twice a day Disp #*30 Tablet Refills: *1 4. OxyCODONE (Immediate Release) ___ mg PO Q4H: PRN pain RX *oxycodone 5 mg ___ tablet(s) by mouth q6hr Disp #*30 Tablet Refills: *0 <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> Cesarean delivery Severe Pre-eclampsia Intrauterine Growth Restriction <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> pelvic rest Please review the discharge packet Continue your home meds
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Ms. ___ is a ___ G1 at 35+2 admitted to the antepartum service with borderline IUGR, oligohydramnios, and elevated blood pressures, who was admitted for rule out pre-eclampsia. *) Rule out pre-eclampsia -> pre-eclam Ms. ___ blood pressures were normal to mild range in triage, and she was asymptomatic. Her pre-eclampsia labs were notable for a urine protein to creatinine of 0.7 and elevated uric acid, but otherwise were within normal limits. Her 24 hour urine was 654. She ultimately had two severe range blood pressures over the course of her antepartum admission and ruled in for pre-eclampsia. *) Fetal well being Ms. ___ was made betamethasone complete on ___. She underwent twice daily NST and twice weekly biophysical profile testing while in house. Her prenatal history was notable for IUGR in the setting of a history of low ___. She had a low risk ERA, but had declined further genetic screening. She had reassuring testing, however had a repeat growth scan on ___ which demonstrated oligohydramnios and EFW 7%. The recommendation was made for delivery. The patient underwent an induction of labor. She had severe range pressures shortly after initiation of her induction and the decision was made to start magnesium for seizure prophylaxis. She received a one time dose of 5mg IV hydralazine with good effect. She received cytotec, a foley bulb, and Pitocin throughout the course of her induction. Ultimately she delivered via primary cesarean section in the setting of a category ___ FHT and fetal intolerance to labor. Her post partum course was uncomplicated. Her blood pressures were monitored closely and she was well controlled with Labetalol 200mg BID. She was discharged home on PPD4 with appropriate outpatient follow up.
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10975450-DS-15
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Latex / Hemabate <ATTENDING> ___ <CHIEF COMPLAINT> Symptomatic fibroid uterus <MAJOR SURGICAL OR INVASIVE PROCEDURE> Total laparoscopic hysterectomy, bilateral salpingectomy, cystoscopy, abdominal flap advancement <HISTORY OF PRESENT ILLNESS> This is a ___ gravida 7, para 3, SAB x1, TAB x3, last menstrual period on ___. The patient notes that she after having thought about her options for the treatment of her increased vaginal bleeding would like definitive therapy in the form of a total hysterectomy. The patient notes that when she has heavy bleeding she uses an entire pack of sanitary pads in a day. She has used observation, hormonal therapy in the form of Depo-Provera, and oral contraceptive pills; however, those treatment modalities lead to weight gain. She is not interested in interventional radiology or minor operative procedures, i.e., hysteroscopy or ablation. . She does have a history of abnormal Pap in ___. She was evaluated by Dr. ___, because of atypical squamous cells of undetermined significance, cannot rule out a high-grade lesion. At that time, he evaluated the patient and colposcopic exam was unrevealing. Repeat Pap showed that she had no lesions consistent with dysplasia or malignancy. Her last Pap was on ___, and also was negative for intraepithelial neoplasia or malignancy. However, given the history, the patient would like removal of her cervix during the time of hysterectomy. . ___ endometrial biopsy showed secretory endometrium. <PAST MEDICAL HISTORY> OBSTETRICS AND GYNECOLOGIC HISTORY: Menses occurs every 28 days. She bleeds heavily for at least four days. She denies dysmenorrhea. She denies intermenstrual or postcoital bleeding. She has a history of perineal and perianal condylomata, which was removed during her last pregnancy and she has not had recurrence. She has a remote history of pelvic inflammatory disease. She is status post tubal ligation. She has a history of uterine fibroids and on ___, ultrasound showed an enlarged uterus that measured 9.3 x 5.8 x 5.9 cm. There were multiple masses consistent with fibroids. The largest fibroid had a calcified rim and was intramural located on the right and measured 3.6 x 3.2 x 2.8 cm. The endometrium was heterogeneous and thickened and measured 23 mm. No vascularity was demonstrated within the endometrium. The right ovary contained a 5-mm shadowing echogenic focus which may represent an old dermoid. The left ovary was normal. There was no free fluid. These findings were discussed with the patient and her questions were answered. . She does have a history of endometriosis as well, status post fulguration in ___. The patient has had seven pregnancies; in ___, termination of twins in second trimester and in ___, primary cesarean at term for cephalopelvic disproportion, that male infant weighed 7 pounds and 4 ounces. There were no complications. Gravida 3 through 5, first trimester termination x2, SAB x1, all requiring D&C, all without complication. Gravida 6, ___, repeat cesarean delivery complicated by preeclampsia and finally gravida 7 scheduled repeat cesarean section at term and this was followed by tubal ligation. . PAST MEDICAL HISTORY: As above, history diagnosed at age ___. She is never hospitalized or intubated. Obesity, history of anemia, and heart murmur at birth. She has had cardiology evaluation in the past, particularly during her asthmatic exacerbations and history of CHF in her ___, workup revealed a ___ systolic ejection murmur. EKG normal. Chest x-ray, no cardiomegaly. Echo showed an ejection fraction of 60-70% during her first trimester pregnancy. Subsequent to that, the patient reported she has had negative workup and no followup recommended. . PAST SURGICAL HISTORY: Cesarean delivery x3 with bilateral tubal ligation, D&C x4, and laparoscopy for endometriosis in ___. Abdominoplasty in ___. . ALLERGIES: Latex causes rash. Hemabate. <SOCIAL HISTORY> ___ <FAMILY HISTORY> Maternal aunt with breast cancer in her mid ___. Paternal grandfather with colon cancer in his ___. Negative history for cervical, uterine, fallopian tube or ovarian cancers. Also, there's a history of cardiac disease and diabetes. Negative history of any clotting or bleeding disorders. <PHYSICAL EXAM> Discharge physical exam Vitals: VSS Gen: NAD, A&O x 3 CV: RRR Resp: no acute respiratory distress Abd: soft, appropriately tender, no rebound/guarding, incision c/d/i Ext: no TTP <MEDICATIONS ON ADMISSION> albuterol, fluticasone, pulmicort, citalopram <DISCHARGE MEDICATIONS> 1. Acetaminophen ___ mg PO Q6H: PRN pain no more than 4g in one 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 RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth four times a day Disp #*50 Capsule Refills: *1 3. OxycoDONE (Immediate Release) ___ mg PO Q4H: PRN pain do not drive while taking medication RX *oxycodone 5 mg 1 tablet(s) by mouth every four (4) hours Disp #*60 Tablet Refills: *0 RX *oxycodone [Oxecta] 5 mg 1 to 2 tablet(s) by mouth every four (4) hours Disp #*50 Tablet Refills: *0 4. Ibuprofen 600 mg PO Q6H: PRN pain take with food RX *ibuprofen 200 mg 1 tablet(s) by mouth four times a day Disp #*50 Tablet Refills: *1 <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> symptomatic fibroid uterus, revision of abdominoplasty <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, and cystoscopy by Gynecology, abdominal flap advancement by Plastic Surgery for symptomatic fibroid uterus, revision of abdominoplasty. 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 oxycodone, ibuprofen, acetaminophen. . By post-operative day 2, she was tolerating a regular diet, voiding spontaneously, ambulating independently, and pain was controlled with oral medications. She was then discharged home in stable condition with outpatient follow-up scheduled.
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10978788-DS-20
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> IV Dye, Iodine Containing Contrast Media <ATTENDING> ___. <CHIEF COMPLAINT> heavy vaginal bleeding <MAJOR SURGICAL OR INVASIVE PROCEDURE> total laparoscopic hysterectomy, bilateral salpingo-oophorectomy <HISTORY OF PRESENT ILLNESS> ___ yo female presents for surgical consultation for EIN found on endometrial biopsy. She reports heavy, painful and abnormal menses x ___ year. She underwent a PUS which revealed Both transabdominal and transvaginal ultrasound were performed a retroverted uterus is present at measures 11.1 by 5.2 x 7.0 cm. No fibroids are identified but there is a heterogenicity and a bulkiness of the uterus. The endometrium measures 14 mm no polyps are identified. The right ovary is normal but a tortuous tube is seen on the right adnexa consistent with a hydro salpingo is in this region.The left ovary is normal. Hydrosalpinx is probable. She then underwent an EMB which showed Endometrial Intraepithelial Neoplasia (EIN). Her LMP was ___. She denies any change in bowel or bladder habits. No VB or vaginal discharge. <PAST MEDICAL HISTORY> PMH: Asthma, Hypothyroid, Anemia, Depression, Anxiety PSH: Laparoscopic Cholecystectomy, right knee surgery OB/GYN: G3P3- NVD x3, Last Pap Smear: ___, h/o HSIL S/P LEEP ___, not sexually active, no h/o fibroid or ovarian cyst <SOCIAL HISTORY> ___ <FAMILY HISTORY> Mother: ___ Cancer at age ___, no ovary, colon or uterine cancer, Father: HTN Physical ___: 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: 08AM BLOOD WBC-8.8# RBC-3.48* Hgb-9.0* Hct-27.1* MCV-78* MCH-26.0* MCHC-33.4 RDW-26.5* Plt ___ ___ 07: 20PM BLOOD WBC-6.7 RBC-3.63* Hgb-8.7* Hct-27.1* MCV-75* MCH-24.0* MCHC-32.1 RDW-17.4* Plt ___ ___ 05: 50AM BLOOD WBC-5.1 RBC-3.17* Hgb-7.9* Hct-24.4* MCV-77* MCH-24.8* MCHC-32.2 RDW-20.8* Plt ___ ___ 06: 08AM BLOOD Glucose-95 UreaN-10 Creat-0.7 Na-139 K-4.3 Cl-106 HCO3-24 AnGap-13 ___ 07: 20PM BLOOD Glucose-108* UreaN-15 Creat-0.8 Na-138 K-3.4 Cl-104 HCO3-24 AnGap-13 ___ 05: 50AM BLOOD Glucose-85 UreaN-12 Creat-0.7 Na-140 K-4.2 Cl-108 HCO3-27 AnGap-9 ___ 06: 08AM BLOOD Calcium-8.6 Phos-3.8 Mg-1.9 <MEDICATIONS ON ADMISSION> albuterol, azelastine nasal spray 2 puffs BID, symbicort, bupropion 150mg daily, clonazepam, fluticasone, levothyroxine 125 mcg, pantoprazole 40mg daily, sertraline 100mg daily, cetirizine 10mg daily <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. 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 take with food RX *ibuprofen 600 mg 1 tablet(s) by mouth pain Disp #*50 Tablet Refills: *1 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 #*50 Tablet Refills: *0 5. Ferrous Sulfate 325 mg PO DAILY take colace if constipated RX *ferrous sulfate 325 mg (65 mg iron) 1 tablet(s) by mouth daily Disp #*30 Tablet Refills: *3 6. Simethicone 40-80 mg PO QID: PRN gas <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> endometrial intraepithelial neoplasia **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 ___ 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 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, toradol and tylenol. Her diet was advanced without difficulty and she was transitioned to ibuprofen, tylenol and oxycodone for pain. On post-operative day #1, her urine output was adequate so her Foley catheter was removed and she voided spontaneously. However after the removal of her foley catheter she was noted to be oliguric despite adquate PO intake so her catheter was replaced and her urine output responded appropriately to an IV fluid bolus. Her catheter was again removed on post-operative day 2 and she was able to void 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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10979046-DS-3
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___ <CHIEF COMPLAINT> FIGO IIIA squamous cell carcinoma of the cervix <MAJOR SURGICAL OR INVASIVE PROCEDURE> 1. Tandem & interstitial implant placement 2. HDR brachytherapy treatment using interstitial implant <HISTORY OF PRESENT ILLNESS> Ms. ___ is ___ ___ female who had vulvar and vaginal itching in ___, treated with clotrimazole cream, then felt a lump on her vagina around ___ or ___. She then noted intermittent vaginal spotting in ___. She saw Dr. ___ at her primary care provider's office on ___, who noted a large friable fungating cervical mass fixed to the anterior vaginal wall on exam, which bled significantly after a speculum and bimanual examination. She was referred to Dr. ___ of ___ and Gynecology at ___ on ___, who again saw 7 cm fungating lesion replacing the cervix. Biopsy that day showed moderately differentiated squamous cell carcinoma. She was referred to Dr. ___ of ___ Oncology on ___, who noted a 6 cm erythematous nodular mass replacing the cervix and extending to the lower third of the vagina, fixed to the pubic bone, with the right parametrial involvement, and obliteration of the right vaginal fornix. There seemed to be no extension to the pelvic sidewall. Pelvic MRI at ___ on ___, demonstrated a 5 x 2.5 x 6.2 cm lobular heterogeneously enhancing soft tissue mass arising from and replacing the anterior vaginal wall, extending to the bilateral vaginal fornices and inferior to the introitus, and protruding anteriorly into the subvaginal fat. There appears to be no involvement of the cervix by MRI. There is no invasion of the bladder or rectum. There is mild endometrial thickening. There was a 1.7 round centrally necrotic right external iliac lymph node, 1.7 cm right common iliac lymph node, and ___ 8 mm right internal iliac lymph node that were all suspicious for disease. The patient says that she has had no vaginal bleeding since ___, although during the exam today, she had a smear of dark brown blood on her pantiliner. She has a moderate amount of clear vaginal discharge and uses two pads per day, which are not soaked through. She says the vaginal mass that she palpated several months ago has since resolved, and she denies any pelvic or abdominal pain or pressure. She has occasional constipation and diarrhea, and takes stool softeners as needed, but denies any rectal bleeding. She has chronic urinary frequency that is unchanged and nocturia x ___. She denies any dysuria, hematuria, or urinary incontinence. She has stable chronic lower extremity edema from varicose veins, greater on the right, for which she uses compression stockings. Of note, over the last three weeks, she has been having wheezing, shortness of breath and nonproductive cough associated with fatigue, loss of appetite and weight loss of 7 pounds. She denies any fevers or chills. She was given antibiotics, has had several nebulizer treatments, and a short course of prednisone with some improvement in her symptoms. However, she still occasionally has wheezing, shortness of breath, and has ___ occasional cough. She saw her primary care provider yesterday who added Flovent to her medications. She had a chest x-ray on ___ that showed hyperexpansion of the lungs with flattened hemidiaphragm consistent with chronic pulmonary disease, mild prominence of interstitial markings at the bases that could reflect chronic lung disease, elevated pulmonary venous pressure, or both. She is scheduled for PFTs in two weeks and will also continue her albuterol p.r.n. REVIEW OF SYSTEMS: As per history of present illness. The patient denies any headache. She has occasional blurry vision and dizziness. Due to the blurry vision from her glaucoma, no chest pain, palpitations, nausea, vomiting, focal muscle weakness or paresthesias, recent falls, depression, anxiety, easy bruising or bleeding. All other systems are negative. PET/CT on ___ showed ___ avid cervical mass, and extensive FDG avid lymphadenopathy in the pelvis, extending superiorly along the aortocaval lymph node chains to the level of the right renal pelvis. There was low-level FDG avidity within the left adrenal gland, possibly ___ adenoma or metastasis. MRI of the abdomen to evaluate the adrenal gland on ___ showed no nodule larger than 8mm, ___ no need for further follow-up of any adrenal abnormalities. She was seen by Dr. ___ on ___ who did not think she was a good candidate for concurrent chemotherapy. Therefore, we will proceed with definitive radiation therapy alone. She has since received multiple treatments with external beam radiation therapy to the pelvic and inguinal lymph nodes. <PAST MEDICAL HISTORY> PAST MEDICAL AND SURGICAL HISTORY: 1. Hypertension. 2. Hyperlipidemia. 3. GERD. 4. Depression 5. Dementia. 6. Seasonal allergies. 7. Glaucoma. 8. Varicose veins. OB/GYN HISTORY: G10 ___ with one set of twins. Menopause in her ___. No prior Pap smears ever. No history of sexually transmitted infections or hormone replacement therapy. She was occasionally still sexually active prior to her diagnosis, but has not been sexually active since ___. <SOCIAL HISTORY> ___ <FAMILY HISTORY> No family history of 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, non-distended, no rebound/guarding GU: resolved hematuria, no vaginal bleeding ___: nontender, nonedematous <PERTINENT RESULTS> ___ 07: 15AM BLOOD WBC-3.4* RBC-3.60* Hgb-10.6* Hct-31.9* MCV-89 MCH-29.4 MCHC-33.2 RDW-13.8 RDWSD-44.8 Plt ___ ___ 07: 15AM BLOOD Glucose-84 UreaN-5* Creat-0.5 Na-140 K-3.6 Cl-103 HCO3-28 AnGap-13 <MEDICATIONS ON ADMISSION> 1. Albuterol inhaler p.r.n. 2. Amlodipine 5 mg daily. 3. Dorzolamide-timolol eyedrops. 4. Fluoxetine 40 mg daily. 5. Fluticasone nasal spray daily. 6. Flovent inhaler b.i.d. 7. Latanoprost eyedrops. 8. Memantine 5 mg b.i.d. 9. Omeprazole 20 mg b.i.d. 10.Pravastatin 40 mg daily. 11.Ranitidine 300 mg at bedtime. 12.Tylenol p.r.n. 13.Aspirin 325 mg daily. 14.Calcium plus vitamin D. 15.Cetirizine 10 mg at bedtime. 16.Colace 100 mg b.i.d. ___ daily. <DISCHARGE MEDICATIONS> 1. Acetaminophen ___ mg PO Q4H: PRN pain Do not exceed 4000 mg in 24 hours. RX *acetaminophen 500 mg 1 tablet(s) by mouth Every 6 hours Disp #*50 Tablet Refills: *0 2. Albuterol Inhaler 2 PUFF IH Q6H: PRN wheeze 3. Amlodipine 5 mg PO DAILY 4. Benzonatate 100 mg PO QHS 5. Dorzolamide 2% Ophth. Soln. 1 DROP BOTH EYES TID 6. Flovent HFA (fluticasone) 220 mcg/actuation inhalation 4 inhalation twice a day 7. Fluoxetine 40 mg PO DAILY 8. Fluticasone Propionate NASAL 2 SPRY NU DAILY 9. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS 10. Memantine 5 mg PO BID 11. Omeprazole 20 mg PO BID 12. OxycoDONE (Immediate Release) 2.5 mg PO Q4H: PRN pain RX *oxycodone [Oxecta] 5 mg 0.5 (One half) tablet(s) by mouth Every 4 hours Disp #*40 Tablet Refills: *0 13. Pravastatin 40 mg PO QPM 14. Ranitidine 300 mg PO QHS 15. Docusate Sodium 100 mg PO BID: PRN Constipation Take if using oxycodone for pain. RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth Twice a day Disp #*50 Capsule Refills: *0 <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> FIGO IIIA squamous cell carcinoma of cervix with significant extension to vagina, & positive pelvic, para-aortic lymph nodes <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Dear Ms. ___, You were admitted to the gynecologic oncology service for brachytherapy. You have recovered well after your treatment, and the team feels that you are safe to be discharged home. * You may notice some vaginal discharge, which is normal. You will be instructed to douche with warm water twice a day until your follow-up visit. * After your implant has been removed, it is normal to experience mild pelvic discomfort, and some irritation of your vagina. You may also experience some discomfort when you urinate or move your bowels. Please be sure to discuss any changes in your urinary or bowel patterns with your nurse. * Your activities depend on how you feel. It is important to balance your activities at home with frequent rest periods, particularly during the first week. * Eating a balanced diet and drinking ___ adequate amount of fluids will help ___ to heal and regain your strength. Please follow these instructions: * Tap water douches ___ times per day (morning and evening). * You may eat a regular diet. * Clean your skin after you urinate or move your bowels (use ___ bottle). * Refrain from sexual intercourse until your follow-up visit. 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 ___ interstitial implant on ___. Please see operative report for full details. She received treatments from ___ until ___ for a total of 5 sessions. She was maintained on bedrest, a clear diet, and loperamide throughout this time. Her pain was controlled with a dilaudid PCA and epidural. On hospital day #2 she developed epidural site bleeding post-brachytherapy. Anesthesia was made aware and felt reassured after changing the dressing. Follow-up CBC and coagulation studies were within normal limits. She was seen by Spiritual Care during her admission. The implant was removed on hospital day #3. *) Frank hematuria: Developed frank hematuria upon implant removal on hospital day #3, likely due to bladder perforation/venous bleed. The foley was therefore continued overnight with close monitoring. Urology was consulted and recommended placing a 3-way ___ foley and start CBI if persistent. She was made NPO and kept on IVF overnight. Her hematuria subsequently resolved later that same night with clear yellow urine. Her Foley catheter was removed on hospital day #4 and she voided spontaneously without any additional hematuria. Her diet was advanced on hospital day #4 without any difficulty and she was transitioned to oral acetaminophen for her pain. By hospital day #4, 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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10979349-DS-5
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> cervical cancer <MAJOR SURGICAL OR INVASIVE PROCEDURE> ROBOTIC ASSISTED LAPAROSCOPIC RADICAL HYSTERECTOMY, BILATERAL PELVIC LYMPH NODE DISSECTION, BILATERAL SALPINGECTOMY <HISTORY OF PRESENT ILLNESS> The patient is a ___ gravida 1, para 1 who underwent colposcopic directed biopsies, which were interpreted as CIN 3 worrisome for invasive carcinoma. She then underwent evaluation by Dr. ___ Gynecologic ___ and further biopsies confirmed an invasive squamous cell carcinoma. A pelvic MRI and CT scan were performed. The pelvic MRI demonstrated enhancing lesion on the left lateral and posterior aspect of the cervix. There was no evidence of parametrial or vaginal wall invasion. There was no pelvic sidewall lymphadenopathy. CT scan of the chest, abdomen and pelvis did not show any evidence of metastatic disease. She was examined by both myself and Dr. ___ we confirmed no evidence of parametrial or vaginal involvement and felt that her disease likely represented a stage IB2 and she would be a candidate for radical hysterectomy. The patient agreed with surgical management. An informed sign consent was obtained with the help of a ___ interpreter following our long discussion. <PAST MEDICAL HISTORY> Past medical history is otherwise negative. Past Surgical History: 1. Laparoscopic appendectomy. 2. Primary cesarean section ___ years ago. 1 pregnancy resulting in c-section due to malpresentation Hx of chlamydia recently dx'd and treated in the ___ Mirena IUD use as noted above Post-coital bleeding No prior history of abnormal pap smears <SOCIAL HISTORY> ___ <FAMILY HISTORY> Negative for breast, uterine, ovarian or colon malignancies. <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, minimally TTP Incision: 5 LSC port sites. c/d/i, mid above umbo with 1cm echymosis on R margin. Dressings: steris GU: mild spotting on pad Foley present draining clear yellow urine. Extremities: no edema, no calf tenderness bilaterally <PERTINENT RESULTS> ___ 07: 05AM BLOOD WBC-13.0* RBC-2.70* Hgb-7.7* Hct-23.4* MCV-87 MCH-28.5 MCHC-32.9 RDW-12.8 RDWSD-40.2 Plt ___ ___ 05: 20PM BLOOD WBC-12.5* RBC-3.34* Hgb-9.5* Hct-28.9* MCV-87 MCH-28.4 MCHC-32.9 RDW-12.7 RDWSD-40.1 Plt ___ ___ 10: 00PM BLOOD WBC-14.0* RBC-3.51* Hgb-10.0* Hct-29.9* MCV-85 MCH-28.5 MCHC-33.4 RDW-13.2 RDWSD-40.3 Plt ___ ___ 08: 44AM BLOOD ___ PTT-33.0 ___ ___ 08: 44AM BLOOD Glucose-130* UreaN-8 Creat-0.5 Na-137 K-3.6 Cl-99 HCO3-27 AnGap-11 CTA Chest ___ IMPRESSION: 1. No pulmonary embolism to segmental level. New bilateral small pleural effusions with compressive atelectasis. 3. Trace free fluid and pneumoperitoneum, partially seen, likely reflecting recent surgery. <MEDICATIONS ON ADMISSION> none <DISCHARGE MEDICATIONS> 1. Acetaminophen ___ mg PO Q6H RX *acetaminophen 500 mg ___ tablet(s) by mouth every 6 hours as needed Disp #*50 Tablet Refills: *2 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. Ibuprofen 600 mg PO Q6H: PRN Pain RX *ibuprofen 600 mg 1 tablet(s) by mouth every 6 hours Disp #*50 Tablet Refills: *2 4. Nitrofurantoin (Macrodantin) 100 mg PO QHS RX *nitrofurantoin macrocrystal [Macrodantin] 100 mg 1 capsule(s) by mouth daily Disp #*12 Capsule Refills: *0 5. TraMADol ___ mg PO Q6H: PRN BREAKTHROUGH PAIN Reason for PRN duplicate override: Alternating agents for similar severity take for pain not relieved with Tylenol and ibuprofen RX *tramadol 50 mg ___ tablet(s) by mouth every 6 hours Disp #*20 Tablet Refills: *0 <DISCHARGE DISPOSITION> Home With Service Facility: ___ <DISCHARGE DIAGNOSIS> cervical cancer <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Dear Ms. ___: . You were admitted to the gynecologic oncology service after undergoing the procedures listed below. You have recovered well after your operation, and the team feels that you are safe to be discharged home. Please follow these instructions: . * 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 4 weeks. * You may eat a regular diet. * It is safe to walk up stairs. . Incision care: * You may shower and allow soapy water to run over incision; no scrubbing of incision. No bath tubs for 6 weeks. * Leave your steri-strips on. If they are still on after ___ days from surgery, you may remove them. . To reach medical records to get the records from this hospitalization sent to your doctor at home, call ___. *** Home with foley: You were discharged home with a Foley (bladder) catheter and received teaching for it prior to discharge. You were also given a prescription for Macrodantin (nitrofurantoin) antibiotic to prevent a UTI while you have the catheter. Please take as prescribed. You should follow-up in Dr. ___ on ___ for catheter removal. ***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 radical hysterectomy, bilateral salpingectomy, bilateral pelvic lymphnode dissection. Please see the operative report for full details. Her post-operative course is detailed as follows. Immediately postoperatively, her pain was controlled with IV morphine, toradol and tylenol. Her diet was advanced without difficulty and she was transitioned to oxycodone, tylenol and ibuprofen. On post-operative day 2, she had a syncopal event due to acute blood loss anemia while followed by a period of loss of orientation. Initially at the time of the event, she desatted to 88% and was placed on 4L nasal cannula. This was shortly weaned off. Labs at the time were notable for a hematocrit of 23, down from pre-op of 40. She received a 1L fluid bolus and 2 units of packed red blood cells with good response in her symptoms and vitals. Given the concern for ongoing bleeding she was made NPO however her vitals and hematocrit remained stable over the course of the day and next morning so her diet was advanced. On post-operative day 3, she had another syncopal event in the setting of sitting up in bed. On evaluations, her hematocrit remained stable, EKG was normal sinus rhythm and CTA was negative for PE. She was also seen by neurology who did not feel her syncope was due to an acute neurologic event including seizure. She had orthostatic vitals take which were negative. After further discussion and evaluation, it was determined that her syncopal episodes were likely due to a combination of acute blood loss anemia and exacerbated by oxycodone use as she had no further episodes after discontinuing use. By post-operative day 4, she was tolerating a regular diet, ambulating independently, and pain was controlled with oral medications. She had no further syncopal events and was ambulating without dizziness. She was then discharged home in stable condition with outpatient follow-up scheduled. Given the nature of her surgery, she was discharged home with a foley catheter with plan for outpatient removal and macrobid for prophylaxis.
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10979349-DS-6
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> Urinary tract infection Fevers <MAJOR SURGICAL OR INVASIVE PROCEDURE> none <HISTORY OF PRESENT ILLNESS> ___ s/p RA-radical hysterectomy, bilateral salpingectomy, B/L pelvic lymphadenectomy on ___ for stage IB2 invasive squamous cell carcinoma of the cervix presenting with sudden-onset pain the evening of ___, also noted to be febrile in the ambulance on the way to the hospital. Her postop course was c/b acute blood loss anemia and syncopal events. She received 2 units of pRBCs on ___ and her hematocrit stabilized. Her w/u for syncope included a CT chest, which was normal, and a normal EKG. She remained stable and was discharged home on ___. She reports she was feeling well until last night (___) when she experienced sudden onset severe and diffuse abdominal pain. Her husband reports she had a near-syncopal event similar to the ones she had had in the hospital. She did not lose consciousness or hit her head. He laid her down and called ___. She denies fevers, though her husband reports that he noted her to have shaking chills. She was first noted to be febrile in the ambulance. Denies CP, SOB, N/V/D, foul-smelling urine from her indwelling catheter, or abnormal vaginal discharge. Passing flatus. Denies VB, though has had dark brown/black vaginal streaking since her surgery. <PAST MEDICAL HISTORY> ONCHx: - ___: Pap smear with HSIL - ___: Colpo bx's at 4, 12, and 8 o'clock with at least CIN3, cannot r/o invasive carcinoma. - ___ Exam showed a friable mass approximately 4 cm with a more firm mass involving the inferior left side of the portion of the cervix possibly extending to the vaginal fornix. Bx showed invasive SCC, no LVI. - ___ CT C/A/P: no e/o metastatic disease or lymphadenopathy - ___ Pelvic MRI: 2.3 cm exophytic lesion from the exocervix, 1.5 cm from the internal os with cervical length of 2.6 cm without evidence of parametrial vaginal wall invasion compatible with stage I B1 cervical carcinoma. No suspicious lymphadenopathy. - ___: RA-radical hysterectomy, BS, B/L pelvic LNDs. Postop course c/b acute blood loss anemia with syncopal events. She received 2 units of pRBCs on ___. She was then discharged home on ___ in stable condition. Path notable for invasive SCC of cervix; endometrium, myometrium, B/L tubes and upper vagina negative. B/L LNDs neg. OBHx: G1P1 - C-section PGynHx: - Denies history of STIs, fibroids, endometriosis, cysts PMHx: - Cervical cancer <SOCIAL HISTORY> ___ <FAMILY HISTORY> Negative for breast, uterine, ovarian or colon malignancies. <PHYSICAL EXAM> Physical Exam on Admission: 01: 00 T 101.4, HR 112, 140/71, RR 18, 97% RA General: Lying in bed comfortably, appears tired. Appears uncomfortable with movement but in NAD. Neuro: alert, appropriate, oriented x 4 HEENT: MMM Cardiac: RRR, no m/g/r Pulm: CTAB Abdomen: soft, moderately distended. diffusely TTP with +mild rebound. GU: small amount of dark blood on pad, Foley in place draining yellow urine. Pelvic: Normal external anatomy, pink vaginal mucosa. moderate white discharge in vault, no erythema. cuff intact without erythema. Bimanual: gentle palpation of cuff reveals intact suture, no palpable mass or induration/fluctuance. Ext: no TTP or edema Physical Exam on Discharge: O: 98.0, 103 / 68, 83, 18, 99 RA I/Os: Last Shift: 0cc PO / 300cc UOP Last 24 hrs: 1200cc PO + 625cc IV / 820cc UOP Gen: well appearing, NAD, sleeping CV: RRR Resp: CTAB, n work of breathing Abd: soft, mildly distended. Mild, diffuse tenderness to palpation. No rebound or guarding. Incisions are clean, dry, and intact. Steri strips removed. GU: Scant, dark spotting on pad Ext: nontender, no edema, p-boots on <PERTINENT RESULTS> ___ 01: 30AM BLOOD WBC-14.1* RBC-3.77* Hgb-10.9* Hct-32.7* MCV-87 MCH-28.9 MCHC-33.3 RDW-13.5 RDWSD-41.0 Plt ___ ___ 01: 30AM BLOOD Neuts-84.5* Lymphs-8.4* Monos-6.3 Eos-0.1* Baso-0.2 Im ___ AbsNeut-11.87* AbsLymp-1.18* AbsMono-0.88* AbsEos-0.02* AbsBaso-0.03 ___ 06: 50AM BLOOD WBC-11.8* RBC-3.21* Hgb-9.3* Hct-28.4* MCV-89 MCH-29.0 MCHC-32.7 RDW-13.5 RDWSD-42.8 Plt ___ ___ 06: 50AM BLOOD Neuts-78.4* Lymphs-13.2* Monos-7.5 Eos-0.1* Baso-0.2 Im ___ AbsNeut-9.26* AbsLymp-1.56 AbsMono-0.88* AbsEos-0.01* AbsBaso-0.02 ___ 03: 25PM BLOOD WBC-12.3* RBC-3.43* Hgb-10.0* Hct-30.2* MCV-88 MCH-29.2 MCHC-33.1 RDW-13.5 RDWSD-41.6 Plt ___ ___ 03: 25PM BLOOD Neuts-76.8* Lymphs-12.8* Monos-9.1 Eos-0.7* Baso-0.2 Im ___ AbsNeut-9.41* AbsLymp-1.57 AbsMono-1.12* AbsEos-0.09 AbsBaso-0.02 ___ 05: 25AM BLOOD WBC-15.7* RBC-3.35* Hgb-9.7* Hct-29.3* MCV-88 MCH-29.0 MCHC-33.1 RDW-13.6 RDWSD-42.9 Plt ___ ___ 05: 25AM BLOOD Neuts-77.3* Lymphs-10.7* Monos-9.0 Eos-1.8 Baso-0.2 Im ___ AbsNeut-12.13* AbsLymp-1.68 AbsMono-1.41* AbsEos-0.29 AbsBaso-0.03 ___ 05: 30AM BLOOD WBC-15.3* RBC-3.44* Hgb-9.8* Hct-30.2* MCV-88 MCH-28.5 MCHC-32.5 RDW-13.4 RDWSD-42.5 Plt ___ ___ 05: 30AM BLOOD Neuts-72.9* Lymphs-13.8* Monos-10.1 Eos-1.9 Baso-0.3 Im ___ AbsNeut-11.16* AbsLymp-2.11 AbsMono-1.55* AbsEos-0.29 AbsBaso-0.04 ___ 01: 30AM BLOOD Glucose-127* UreaN-13 Creat-0.6 Na-136 K-4.2 Cl-98 HCO3-22 AnGap-16 ___ 09: 22AM BLOOD Glucose-117* UreaN-8 Creat-0.5 Na-138 K-4.0 Cl-105 HCO3-25 AnGap-8* ___ 01: 42AM BLOOD Glucose-146* UreaN-8 Creat-0.6 Na-136 K-3.6 Cl-100 HCO3-22 AnGap-14 ___ 06: 46AM BLOOD Glucose-130* UreaN-6 Creat-0.5 Na-136 K-4.4 Cl-100 HCO3-25 AnGap-11 ___ 05: 25AM BLOOD Glucose-100 UreaN-8 Creat-0.6 Na-140 K-4.1 Cl-100 HCO3-26 AnGap-14 ___ 01: 30AM BLOOD ALT-118* AST-102* AlkPhos-84 TotBili-1.9* ___ 09: 22AM BLOOD ALT-82* AST-54* AlkPhos-73 TotBili-1.5 ___ 06: 46AM BLOOD ALT-72* AST-37 AlkPhos-89 TotBili-2.1* ___ 05: 25AM BLOOD ALT-56* AST-26 ___ 05: 30AM BLOOD ALT-59* AST-35 ___ 09: 22AM BLOOD Calcium-7.8* Phos-3.5 Mg-1.6 ___ 01: 42AM BLOOD Calcium-8.4 Phos-3.1 Mg-1.7 ___ 05: 25AM BLOOD Calcium-8.6 Phos-3.6 Mg-2.0 ___ 01: 44AM BLOOD Lactate-2.1* ___ 09: 36AM BLOOD Lactate-0.9 ___ 01: 45AM BLOOD Lactate-1.3 **FINAL REPORT ___ URINE CULTURE (Final ___: ESCHERICHIA COLI. >100,000 CFU/mL. PRESUMPTIVE IDENTIFICATION. Cefazolin interpretative criteria are based on a dosage regimen of 2g every 8h. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ESCHERICHIA COLI | AMPICILLIN------------ 4 S AMPICILLIN/SULBACTAM-- <=2 S CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- <=16 S PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S ___ 4: 21 am SWAB Source: Vaginal. **FINAL REPORT ___ SMEAR FOR BACTERIAL VAGINOSIS (Final ___: GRAM STAIN NEGATIVE FOR BACTERIAL VAGINOSIS. 1+ (<1 per 1000X FIELD): BUDDING YEAST. YEAST VAGINITIS CULTURE (Final ___: YEAST. SPARSE GROWTH. Blood Culture: pending CT ABD & PELVIS WITH CONTRAST Study Date of ___ 2: 31 AM IMPRESSION: 1. Large pelvic hematoma, with large volume hemoperitoneum. Possible site of venous extravasation in the left hemipelvis vs prominent gonadal veins. 2. 4.5 x 4.0 x 4.1 cm rim enhancing fluid collection in the right hemipelvis could reflect an ovarian cyst, however superinfection cannot be excluded. A tubular structure adjacent to this could reflect a separate forming fluid collection or a loop of bowel although it is difficult to definitively characterize. 3. Free intraperitoneal air is likely postoperative. 4. Small right and trace left hemorrhagic pleural effusions. <MEDICATIONS ON ADMISSION> ibuprofen, macrobid, ultram, tylenol <DISCHARGE MEDICATIONS> 1. Ciprofloxacin HCl 500 mg PO Q12H Duration: 5 Days RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth twice a day Disp #*12 Tablet Refills: *0 2. Acetaminophen 1000 mg PO Q6H: PRN Pain - Mild 3. Docusate Sodium 100 mg PO BID <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> catheter associated urinary tract infection <DISCHARGE CONDITION> stable <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Dear Ms. ___, You were admitted to the hospital for fevers after your surgery. There was bacteria in your urine and it was thought that the fever was due to a urinary tract infection. Your fevers have resolved and the team believes it is safe for you to return home. It is important that you finish all your antibiotics. You should continue to follow all the post-op instructions given to you after your surgery last week.
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Ms. ___ was admitted to the gynecology oncology service after presenting with abdominal pain and fevers. On initial presentation, she was initiated on IV vancomycin and zosyn with concern for infection. Initial CT scan on ___ in the ED showed an 8.4cm pelvic hematoma with a 4.5cm rim enhancing fluid collection with concern for pelvic abscess vs ovarian cyst. While in the hospital, patient's Hct was stable while she was in the hospital. ___ was consulted, and it was decided that hematoma was not able to be drained. She was noted to have a mild transaminitis upon presentation that improved while she was admitted, thought to be due to hematoma. Patient was found to have a UTI on hospital day 2, and her antibiotics were switched to PO cipro x 7 days given sensitivities. Patient's foley was removed prior to discharge, and she was able to void spontaneously after a trial of void. On hospital day 3, patient was doing well with pain well controlled on PO pain medications. She was voiding spontaneously, ambulating independently, and tolerating PO. Her exam was found to be reassuring, and she was discharged home in stable condition.
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10979349-DS-7
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> lower abdominal pain <MAJOR SURGICAL OR INVASIVE PROCEDURE> none <PHYSICAL EXAM> PHYSICAL EXAM AT DISCHARGE -========= Temp: 98.8 (Tm 99.4), BP: 91/58 (91-104/58-68), HR: 70 (70-86), RR: 16 (___), O2 sat: 98% (96-98), O2 delivery: Ra, Wt: 146.8 lb/66.59 kg 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 GU: serosanguinous discharge Foley: present draining pale yellow urine Extremities: no calf tenderness, no edema wwp, pboots on and active bilaterally <PERTINENT RESULTS> ___ 02: 45PM BLOOD WBC-14.5* RBC-3.85* Hgb-10.7* Hct-33.6* MCV-87 MCH-27.8 MCHC-31.8* RDW-12.9 RDWSD-40.7 Plt ___ ___ 07: 40AM BLOOD WBC-9.5 RBC-3.68* Hgb-10.5* Hct-32.3* MCV-88 MCH-28.5 MCHC-32.5 RDW-13.0 RDWSD-40.9 Plt ___ ___ 07: 40AM BLOOD Neuts-61.3 ___ Monos-13.3* Eos-3.8 Baso-0.3 Im ___ AbsNeut-5.79 AbsLymp-1.96 AbsMono-1.26* AbsEos-0.36 AbsBaso-0.03 ___ 07: 40AM BLOOD Glucose-89 UreaN-7 Creat-0.6 Na-141 K-4.8 Cl-102 HCO3-29 AnGap-10 - ___ 6: 10 pm URINE **FINAL REPORT ___ URINE CULTURE (Final ___: < 10,000 CFU/mL. Color Yellow Appear Hazy SpecGr 1.023 pH 6.0 Urobil Neg Bili Neg Leuk Neg Bld Neg Nitr Neg Prot Tr Glu Neg Ket Neg RBC 2 WBC 4 Bact Few Yeast None Epi 26 Other Urine Counts Mucous: Mod - XAMINATION: CT abdomen and pelvis with contrast. INDICATION: ___ with abdominal and pelvic pain. Recent hysterectomy. Evaluate for abscess. TECHNIQUE: Single phase split bolus contrast: MDCT axial images were acquired through the abdomen and pelvis following intravenous contrast administration with split bolus technique. Oral contrast was not administered. Coronal and sagittal reformations were performed and reviewed on PACS. DOSE: Acquisition sequence: 1) Stationary Acquisition 3.5 s, 0.5 cm; CTDIvol = 16.9 mGy (Body) DLP = 8.4 mGy-cm. 2) Spiral Acquisition 6.4 s, 50.1 cm; CTDIvol = 11.6 mGy (Body) DLP = 579.0 mGy-cm. Total DLP (Body) = 587 mGy-cm. COMPARISON: CT abdomen and pelvis ___. FINDINGS: LOWER CHEST: Compared to most recent prior study, the small right pleural effusion has decreased in size with adjacent mild compressive atelectasis. Mild left basilar atelectasis is improved. Heart size is normal. There is no evidence of pericardial effusion. ABDOMEN: HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout. There is no evidence of focal lesions. There is no evidence of intrahepatic or extrahepatic biliary dilatation. The gallbladder is 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: Focal, wedge-shaped hypodensities of the right kidney (2: 39, 601: 30), creating a striated nephrogram, appear new. The kidneys are of normal and symmetric size. No hydronephrosis is seen in either kidney. The left ureter, however, demonstrates diffuse moderate dilatation, with ureteral wall thickening and urothelial hyperenhancement, most pronounced in the distal ureter. A caliber change in the left ureter is noted within its distal segment as it courses adjacent to a pelvic fluid collection and appears to be extrinsically compressed by it. The right ureter appears normal. 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 surgically absent. The previously seen hemoperitoneum along the bilateral pericolic gutters, along with pneumoperitoneum, appears to have largely resolved. PELVIS: A locule of air is within the anterior bladder (2: 68. Fat stranding and free fluid within the pelvis appears improved from the prior study. REPRODUCTIVE ORGANS: The uterus is surgically absent. Compared to the most recent prior study, the previously seen pelvic hematoma within the hysterectomy bed, appears decreased in size and has evolved into a lobulated, circumscribed, rim enhancing, thick-walled, fluid collection with more hypodense contents measuring 6.3 x 4.9 x 5.4 cm (2: 71, 601: 30), previously 8.4 x 6.8 x 6.4 cm. The cystic structure with rim enhancement in the right adnexa has decreased in size and now measures 2.7 x 1.9 x 2.2 cm (2: 68, 601: 28), previously 4.5 x 4 x 4.1 cm. Left ovary is normal. LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There is no pelvic or inguinal lymphadenopathy. VASCULAR: There is no abdominal aortic aneurysm. No atherosclerotic disease is noted. BONES: There is no evidence of worrisome osseous lesions or acute fracture. SOFT TISSUES: Postsurgical changes of the anterior abdominal wall are re-demonstrated. IMPRESSION: 1. Interval decrease in size of an evolving pelvic hematoma within the hysterectomy bed, which now appears as a discrete, thick-walled rim enhancing fluid collection measuring 6.3 x 4.9 x 5.4 cm. Superimposed infection of this fluid collection, however, certainly cannot be excluded, as an abscess can have similar imaging features. 2. New, right pyelonephritis. 3. New, moderate left hydroureter, secondary to compression of the distal ureter by the aforementioned pelvic fluid collection. Thickening of the left ureteral wall with urothelial hyperenhancement could indicate inflammation or a superimposed infection. 4. New locule of air within the bladder, which may be due to prior instrumentation or infection. Recommend correlation with clinical history. 5. Interval decrease in size of a right adnexal cystic structure, which is probably a physiologic ovarian cyst, although a superimposed infection cannot be completely excluded. 6. Mild interval decrease in size of a right pleural effusion, which remains small. RECOMMENDATION(S): Recommend correlation with urinalysis and clinical history of recenet bladder instrumentation to account for the presence of a new locule of air within the bladder lumen. <DISCHARGE INSTRUCTIONS> Dear Ms. ___: You are admitted to the gynecologic oncology service after you developed abdominal pain. you had a CAT scan of your abdomen which showed the hematoma (collection of blood) in your pelvis had gotten smaller. We checked her blood and there were no signs of infection. You had a Foley catheter inserted for urinary retention, and we recommend you keep this in until next ___. Please take the prescribed antibiotic at night every day until the catheter is removed. Please refer to your discharge packet from your original surgery for additional information. *** Home with foley: You were discharged home with a Foley (bladder) catheter and received teaching for it prior to discharge. You were also given a prescription for Macrodantin (nitrofurantoin) antibiotic to prevent a UTI while you have the catheter. Please take as prescribed. You should follow-up in the ___ clinic on ___ for catheter removal. Please call for an appointment.
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Ms. ___ presented to the ED with worsening abdominal pain. She underwent a CT of the abdomen and pelvis which showed interval decrease in the size of her known pelvic hematoma, with new rim enhancement concerning for possible infection. There was also concern on imaging for left pyelonephritis. A foley catheter was placed given concern for urinary retention. She was started on a course of IV cetriaxone, and admitted to the GYN ONC service for observation overnight. On HD1, she remained afebrile, CBC did not show leukocytosis. Her pain was controlled with oral medication, and her abdominal pain was found to improve. She was discharged home in stable condition with a foley catheter to be removed at her follow up appointment in clinic. She was prescribed a short course of pyridium for bladder irritation from the foley catheter, as well as prophylactic macrodantin. Discharge Medications: 1. Nitrofurantoin (Macrodantin) 100 mg PO QHS RX *nitrofurantoin macrocrystal [Macrodantin] 100 mg 1 capsule(s) by mouth daily at bedtime Disp #*6 Capsule Refills:*0 2. Phenazopyridine 100 mg PO TID Duration: 3 Days RX *phenazopyridine 100 mg 1 tablet(s) by mouth three times per day as needed Disp #*7 Tablet Refills:*0 3. Acetaminophen ___ mg PO Q6H:PRN Pain - Mild 4. Docusate Sodium 100 mg PO BID 5. Ibuprofen 600 mg PO Q6H:PRN Pain - Mild Reason for PRN duplicate override: Alternating agents for similar severity Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: abdominal pain cervical cancer Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___
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10979566-DS-22
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> Metastatic colon cancer <MAJOR SURGICAL OR INVASIVE PROCEDURE> LAPAROSCOPIC EXTENSIVE ENTEROLYSIS AND LYSIS OF ADHESIONS, BILATERAL URETEROLYSIS, TOTAL LAPAROSCOPIC HYSTERECTOMY, BILATERAL SALPINGO-OOPHORECTOMY, CYSTOSCOPY AND RIGID PROCTOSCOPY <HISTORY OF PRESENT ILLNESS> ___ is a lovely ___ gravida 1 para 1 with an indolent stage IV rectal adenocarcinoma on capecitabine and newly enlarging bilateral adnexal lesions and an enlarging pelvic cystic mass, ? inclusion cyst versus hydrosalpinx. Please see full oncologic history below. She is here to discuss surgery. Today, she reports over the weekend she began having some abdominal discomfort which has now improved but she is worried it is coming from the masses. She is also concerned about her rising tumor marker. At our last visit she had many concerns about future ovarian function, fertility, today she states she is not worried about this anymore and okay if both ovaries need to be removed. With regard to her imaging: Most recent pelvic MRI performed on ___ demonstrated a large lobular multiloculated cystic lesion that has been present on prior imaging and thought to represent a possible inclusion cyst or hydrosalpinx. It increased in size measuring 20.1 x 10.1 cm previously measuring 17.4 x 8.7 cm. Additionally, there is a right pelvic mass with peripheral enhancement and central necrosis measuring 5.3 x 5.8 cm. And a left adnexal cystic lesion with rim enhancement measuring 5.6 x 4 cm. The right adnexal lesion in particular is concerning for a metastatic lesion. Tumor markers were sent and her CA 125 was 19. Her CEA has slowly been rising since ___ from 2.2 to now 15.4. <PAST MEDICAL HISTORY> ONCOLOGIC HISTORY: Low grade stage IV rectal adenocarcinoma metastatic to the liver and lung. In ___ she was diagnosed with a low-grade rectal adenocarcinoma with intact MSI testing metastatic to her liver at diagnosis. She initiated FOLFOX with bevacizumab, Vit D on clinical trial in ___. Shortly thereafter in ___ she presented with bowel obstruction and perforation. She then underwent an LAR and colostomy and ___ procedure. This was followed with continued systemic treatment on clinical trial through ___ after 28 cycles on trial. On ___ she initiated treatment with capecitabine (2wks on/1wk off) which she is currently on, initiating cycle 29 on ___. She reports she has been feeling well on this regimen, working full-time with no concerning symptoms. No other new updates to her history below: PMH: Colon cancer as above, PE ___ on anticoagulation PSH: 1. Laparoscopic appendectomy in ___ 2. Laparoscopic ovarian cystectomy in ___ 3. Hemorrhoid surgery in ___ 4. C-section in ___ (___) 5. XL, LAR, end colostomy and ___ procedure ___ ___ 6. Reversal of ___ procedure with low colorectal anastomosis ___ ___ POBHx: G1P1 - C-section (___) PGYNHx: Menarche age ___. LMP ___, reports regular monthly last menses occurring every 28 days and lasting 4 days of light flow. She is not currently sexually active. She is not using any birth control. She is never taken HRT. Last Pap in ___. Denies abnormal Pap smears. Reports she was diagnosed with PCOS in the past. Denies any history of STI's or pelvic infections. <SOCIAL HISTORY> ___ <FAMILY HISTORY> No family history of breast, ovarian, uterine or colon cancers. Family history of heart kidney and stroke on her maternal side. She has no known history of genetic susceptibility to cancer. <PHYSICAL EXAM> PHYSICAL EXAM at Pre-op Vital Signs sheet entries for ___: BP: 118/72. Weight: 150. BMI: 25.0. EXAM FROM ___ CONSTITUTIONAL: Well appearing, NAD NEURO: A&Ox3, normal gait PSYCH: Normal affect HEENT: NCAT, EOMI, Sclera anicteric, Neck supple, no masses LYMPH NODES: No supraclavicular, cervical or inguinal adenopathy. PULM: CTAB, no wheeze, crackles CV: RRR, normal S1 and S2, no murmurs GI: Soft, ND, NT. No hepatosplenomegaly, no masses palpable GU: No CVA tenderness, NEFG, normal urethral meatus. Normal vaginal vault no blood or discharge, cervix without lesions, but deviated anteriorly and to patient's left. Bimanual: Smooth vaginal walls, cervix without lesions. Somewhat fixed, minimally mobile, sharply anteverted uterus, nontender. Soft palpable mass filling lower pelvis greater on the right. On rectovaginal exam a firm somewhat mobile 4-5 cm mass palpable in the patient's right, no discrete left adnexal mass appreciated. Rectovaginal: Normal tone, smooth RV septum, no nodularity. MSK: Extremities WWP. ___ without edema, nontender. Physical Exam on day of discharge ___ 0340 Temp: 98.7 PO BP: 99/64 L Lying HR: 78 RR: 18 O2 sat: 97% O2 delivery: RA ___ Total Intake: 2327ml PO Amt: 800ml IV Amt Infused: 1527ml ___ Total Output: 810ml Urine Amt: 810ml ___ Total Output: 3150ml Urine Amt: 3150ml General: NAD, comfortable, sitting up in bed, actively conversing CV: RRR, normal s1 and s2, no m/r/g Lungs: normal work of breathing, CTAB Abdomen: soft, softly-distended, nontender to palpation, no rebound, incisions clean/dry/intact GU: pad with no spotting Extremities: no edema, no TTP, pneumoboots in place bilaterally. ___ mildly edematous. Nontender <PERTINENT RESULTS> ___ 09: 05AM BLOOD WBC-6.5 RBC-3.13* Hgb-10.1* Hct-30.7* MCV-98 MCH-32.3* MCHC-32.9 RDW-13.6 RDWSD-49.4* Plt ___ ___ 02: 15AM BLOOD WBC-7.2 RBC-2.70* Hgb-8.9* Hct-27.5* MCV-102* MCH-33.0* MCHC-32.4 RDW-14.3 RDWSD-52.6* Plt ___ ___ 10: 15PM BLOOD WBC-14.2* RBC-3.25* Hgb-10.7* Hct-33.3* MCV-103* MCH-32.9* MCHC-32.1 RDW-14.3 RDWSD-54.2* Plt ___ ___ 02: 15AM BLOOD Neuts-65.2 ___ Monos-8.8 Eos-5.0 Baso-0.4 Im ___ AbsNeut-4.67 AbsLymp-1.45 AbsMono-0.63 AbsEos-0.36 AbsBaso-0.03 ___ 10: 15PM BLOOD Neuts-83.9* Lymphs-4.5* Monos-11.2 Eos-0.0* Baso-0.1 Im ___ AbsNeut-11.90* AbsLymp-0.64* AbsMono-1.58* AbsEos-0.00* AbsBaso-0.01 ___ 09: 45PM BLOOD ___ PTT-25.0 ___ ___ 05: 20PM BLOOD ___ PTT-93.2* ___ ___ 10: 15AM BLOOD ___ PTT-25.3 ___ ___ 02: 15AM BLOOD ___ PTT-23.7* ___ ___ 05: 35AM BLOOD ___ PTT-21.6* ___ ___ 09: 05AM BLOOD Glucose-115* UreaN-6 Creat-0.6 Na-139 K-3.9 Cl-104 HCO3-25 AnGap-10 ___ 02: 15AM BLOOD Glucose-90 UreaN-6 Creat-0.7 Na-136 K-4.1 Cl-102 HCO3-25 AnGap-9* ___ 10: 15PM BLOOD Glucose-194* UreaN-10 Creat-0.9 Na-139 K-3.9 Cl-104 HCO3-17* AnGap-18 ___ 09: 05AM BLOOD Calcium-8.7 Phos-2.9 Mg-1.9 ___ 02: 15AM BLOOD Calcium-7.8* Phos-1.8* Mg-1.8 ___ 10: 15PM BLOOD Calcium-8.3* Phos-4.5 Mg-2.1 Imaging: Upper ___ Ultrasound FINDINGS: There is acute, occlusive thrombus in the distal left internal jugular vein extending down to the left clavicle. There is normal flow with respiratory variation in the left subclavian vein. The left axillary veins are patent, show normal color flow and compressibility. The left brachial, basilic, and cephalic veins are patent, compressible and show normal color flow. IMPRESSION: 1. Acute, occlusive deep vein thrombosis in the distal left internal jugular vein extending down to the left clavicle. 2. No evidence of deep vein thrombosis in the left subclavian, axillary or upper extremity veins. <MEDICATIONS ON ADMISSION> - Eliquis 2.5mg daily - Capecitabine 1000mg BID x2 weeks, 1 week off <DISCHARGE MEDICATIONS> 1. Acetaminophen ___ mg PO Q6H: PRN Pain - Mild/Fever Do not exceed 4000mg in a day RX *acetaminophen 500 mg ___ tablet(s) by mouth q6h prn Disp #*40 Tablet Refills: *0 2. Docusate Sodium 100 mg PO BID RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day Disp #*40 Capsule Refills: *0 3. Enoxaparin Sodium 70 mg SC BID RX *enoxaparin 80 mg/0.8 mL 70 mg SC twice a day Disp #*60 Syringe Refills: *1 4. HYDROmorphone (Dilaudid) ___ mg PO Q4H: PRN Pain - Moderate Reason for PRN duplicate override: Alternating agents for similar severity Do not drive or drink alcohol while taking medication RX *hydromorphone [Dilaudid] 2 mg ___ tablet(s) by mouth q4h prn Disp #*20 Tablet Refills: *0 5. Ibuprofen 600 mg PO Q6H: PRN Pain Do not exceed 2400mg in a day. Take with food RX *ibuprofen 600 mg 1 tablet(s) by mouth q6h prn Disp #*40 Tablet Refills: *0 <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> Recurrent 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: POST OPERATIVE 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 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 your 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. 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 a total laparoscopic hysterectomy, bilateral salpingo-oophorectomy, extensive enterolysis and lysis of adhesion, bilateral ureterolysis, cystoscopy, and rigid proctoscopy for recurrent colon 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 pain medication. Her diet was advanced to clear liquids until she was able to pass flatus. She was then slowly transitioned to regular diet with no issues with emesis or nausea. She tolerated PO pain medication well. On post-operative day #2, her urine output was adequate so her Foley catheter was removed and she voided spontaneously. She was able to ambulate spontaneously. On post-operative day #3, it was noticed that her left upper arm was swollen. Patient reported no pain, but had reported pain lower in her arm the day prior. An upper extremity ultrasound was ordered, and patient was found to have an acute, occlusive DVT or her left IJ. Heme-Onc was consulted, and patient was transitioned from Lovenox 90mg QD to a heparin gtt. She was then transitioned later that day to Lovenox 70mg BID. Patient continued to do well while in the hospital. By post-operative day #4, she was tolerating a regular diet, voiding spontaneously, ambulating independently, passing flatus, having small bowel movements, and pain was controlled with oral medications. She was then discharged home in stable condition with outpatient follow-up scheduled with heme/onc and gyn onc. She was discharged home on Lovenox.
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> nausea, vomiting <MAJOR SURGICAL OR INVASIVE PROCEDURE> ___ guided drainage of pelvic collection <HISTORY OF PRESENT ILLNESS> HPI: ___ yo G1P1 with stage IV rectal adenocarcinoma on apecitabine s/p laparoscopic extensive enterolysis and lysis of adhesions, bilateral ureterolysis, total laparoscopic hysterectomy, bilateral salpingo-oophorectomy, cystoscopy and rigid proctoscopy on ___ who presents to ED with abdominal pain, nausea, and emesis. Admitted to hospital post-op from ___ to ___. Post-op course complicated by upper extremity swelling. An upper extremity ultrasound was ordered, and patient was found to have an acute, occlusive DVT or her left IJ. Heme-Onc was consulted, and patient was transitioned from Lovenox 90mg QD to a heparin gtt. She was then transitioned later that day to Lovenox 70mg BID. Intra-operatively found to have: 1. Extensive adhesions of the small and large bowel and omentum to the anterior abdominal wall, pelvic masses and uterus. 2. Dense retroperitoneal fibrosis. 3. A 20-cm right cystic mass ruptured intraoperatively with an 8 cm solid right ovarian mass adherent to the bowel, pelvic sidewall, right uterosacral, rectosigmoid and posterior cervix. 4. Approximately 10- to 15-cm left cystic mass ruptured intraoperatively with splayed outl ovarian tissue and areas of fibrosis, concerning for cancer similar to that seen on the right. This left ovary was also adherent to bowel, pelvic side wall, left uterosacral and rectosigmoid. 5. Normal cystoscopy with bilateral ureteral jets. 6. Normal rigid proctoscopy with negative bubble test. 7. No other obvious evidence of intra-abdominal disease, upper abdominal survey best performed after extensive lysis of adhesions demonstrated smooth hemidiaphragms. No obvious surface liver lesions, normal-appearing omentum and bowel mesenteric surfaces. This survey was limited by her dense adhesions. Her pathology has since returned: Ovary with metastatic mucinous adenocarcinoma with intestinal differentiation, morphologically compatible with spread from the patient's rectal primary. This afternoon around 1700 she experienced nausea/vomiting after eating a sandwich. Since then she has had progressively worsening abdominal pain. Had 5 episodes of dark brown emesis at home, as well as additional episodes in ED. Last BM today at 1400, prior to this she had a BM ___. Passing flatus. Denies fevers, reports positive chills/shakes. Nausea has resolved since arriving to ED, though continues to have pain. Prior to today, her pain had been well controlled post-op and had only been requiring Tylenol and Motrin. Reports scant vaginal bleeding on wiping, otherwise no other vaginal complaints. <PAST MEDICAL HISTORY> OB: G1P1 - C-section (___) GYN: - LMP: n/a - She is not currently sexually active. - Last Pap in ___. Denies abnormal Pap smears. - Denies any history of STI's or pelvic infections. PMH: - Low grade stage IV rectal adenocarcinoma metastatic to the liver and lung. In ___ she was diagnosed with a low-grade rectal adenocarcinoma with intact MSI testing metastatic to her liver at diagnosis. She initiated FOLFOX with bevacizumab, Vit D on clinical trial in ___. Shortly thereafter in ___ she presented with bowel obstruction and perforation. She then underwent an LAR and colostomy and ___ procedure. This was followed with continued systemic treatment on clinical trial through ___ after 28 cycles on trial. On ___ she initiated treatment with capecitabine (2wks on/1wk off) which she is currently on, initiating cycle 29 on ___. She reports she has been feeling well on this regimen, working full-time with no concerning symptoms. - PE ___ on anticoagulation (previously on Eliquis 2.5mg daily) - Left upper extremity DVT on therapeutic lovenox - Nephrolithiasis s/p tx many years ago PSH: - Laparoscopic appendectomy in ___ - Laparoscopic ovarian cystectomy in ___ - Hemorrhoid surgery in ___ - C-section in ___ (___) - XL, LAR, end colostomy and ___ procedure ___ ___ - Reversal of ___ procedure with low colorectal anastomosis ___ ___ - Laparoscopic extensive enterolysis and lysis of adhesions, bilateral ureterolysis, total laparoscopic hysterectomy, bilateral salpingo-oophorectomy, cystoscopy and rigid proctoscopy Meds: - Capecitabine 1000mg BID x2 weeks, 1 week off - Enoxaparin Sodium 70 mg SC BID - Colace - Tylenol ALL: NKDA <SOCIAL HISTORY> ___ <FAMILY HISTORY> No family history of breast, ovarian, uterine or colon cancers. Family history of heart kidney and stroke on her maternal side. She has no known history of genetic susceptibility to cancer. <PHYSICAL EXAM> --==== ADMISSION EXAM --==== Vitals: 97.6 111 18 117/65 100% RA General: NAD, uncomfortable, intermittently moaning with movement, pleasant Resp: breathing comfortably Abd: moderately distended, +bowel sounds, vertical mini-lap inferior to umbilicus dressed with steris - healing well, no e/o infection, diffuse moderate tenderness throughout, >RLQ, no rebound, +voluntary guarding, not an acute abdomen Ext: nontender no edema Pelvic: normal external genitalia, normal vaginal mucosa, upon placing speculum vagina partially filled with brown/red (old) serous fluid, non-purulent in appearance, non-malodorous, cuff visually normal, no evidence of defect or infection grossly, intact entirely on digital palpation Msk: +mild left CVA tenderness --======== PHYSICAL EXAM ON DISCHARGE: --======== On day of discharge: Afebrile, vitals stable Gen: No acute distress CV: RRR Pulm: CTAB Abd: soft, appropriately tender, nondistended, well healed surgical scar, no rebound/guarding ___: non-tender, non-edematous <PERTINENT RESULTS> --======== RELEVANT LABS: --======== CBC ___ 12: 45AM BLOOD WBC-12.9* RBC-3.00* Hgb-9.6* Hct-28.6* MCV-95 MCH-32.0 MCHC-33.6 RDW-13.2 RDWSD-46.5* Plt ___ ___ 09: 32AM BLOOD WBC-11.3* RBC-2.79* Hgb-8.7* Hct-27.3* MCV-98 MCH-31.2 MCHC-31.9* RDW-13.4 RDWSD-48.3* Plt ___ ___ 04: 39AM BLOOD WBC-7.1 RBC-2.81* Hgb-9.0* Hct-27.4* MCV-98 MCH-32.0 MCHC-32.8 RDW-13.4 RDWSD-48.6* Plt ___ ___ 06: 04AM BLOOD WBC-5.2 RBC-2.93* Hgb-9.3* Hct-28.1* MCV-96 MCH-31.7 MCHC-33.1 RDW-13.2 RDWSD-47.1* Plt ___ ___ 06: 28AM BLOOD WBC-4.7 RBC-2.94* Hgb-9.2* Hct-28.2* MCV-96 MCH-31.3 MCHC-32.6 RDW-13.3 RDWSD-46.6* Plt ___ ___ 06: 36AM BLOOD WBC-5.1 RBC-2.83* Hgb-9.0* Hct-27.3* MCV-97 MCH-31.8 MCHC-33.0 RDW-13.6 RDWSD-47.8* Plt ___ DIFF ___ 12: 45AM BLOOD Neuts-82.2* Lymphs-9.1* Monos-6.1 Eos-0.9* Baso-0.5 Im ___ AbsNeut-10.59* AbsLymp-1.17* AbsMono-0.79 AbsEos-0.11 AbsBaso-0.06 ___ 09: 32AM BLOOD Neuts-75.1* Lymphs-15.0* Monos-8.4 Eos-0.4* Baso-0.4 Im ___ AbsNeut-8.48* AbsLymp-1.69 AbsMono-0.95* AbsEos-0.05 AbsBaso-0.05 ___ 06: 04AM BLOOD Neuts-54.1 ___ Monos-11.4 Eos-4.6 Baso-1.2* Im ___ AbsNeut-2.80 AbsLymp-1.44 AbsMono-0.59 AbsEos-0.24 AbsBaso-0.06 ___ 06: 28AM BLOOD Neuts-57.5 ___ Monos-12.3 Eos-2.2 Baso-1.1* Im ___ AbsNeut-2.68 AbsLymp-1.21 AbsMono-0.57 AbsEos-0.10 AbsBaso-0.05 ___ 06: 36AM BLOOD Neuts-47.3 ___ Monos-16.1* Eos-3.9 Baso-0.8 Im ___ AbsNeut-2.43 AbsLymp-1.60 AbsMono-0.83* AbsEos-0.20 AbsBaso-0.04 BMP ___ 12: 45AM BLOOD Glucose-115* UreaN-7 Creat-0.8 Na-143 K-4.6 Cl-103 HCO3-24 AnGap-16 ___ 09: 32AM BLOOD Glucose-87 UreaN-5* Creat-0.6 Na-140 K-4.7 Cl-108 HCO3-24 AnGap-8* ___ 04: 39AM BLOOD Glucose-83 UreaN-4* Creat-0.6 Na-140 K-4.1 Cl-107 HCO3-24 AnGap-9* ___ 06: 04AM BLOOD Glucose-80 UreaN-4* Creat-0.7 Na-138 K-4.1 Cl-101 HCO3-26 AnGap-11 ___ 06: 28AM BLOOD Glucose-74 UreaN-5* Creat-0.6 Na-139 K-4.2 Cl-104 HCO3-25 AnGap-10 ___ 06: 36AM BLOOD Glucose-90 UreaN-5* Creat-0.6 Na-142 K-4.5 Cl-108 HCO3-26 AnGap-8* ELECTROLYTES ___ 09: 32AM BLOOD Calcium-8.6 Phos-3.9 Mg-2.0 ___ 04: 39AM BLOOD Calcium-8.7 Phos-3.8 Mg-1.8 ___ 06: 04AM BLOOD Calcium-8.6 Phos-3.8 Mg-1.8 ___ 06: 28AM BLOOD Calcium-8.6 Phos-3.0 Mg-2.0 ___ 06: 36AM BLOOD Calcium-8.5 Phos-3.3 Mg-1.9 LFTs ___ 12: 45AM BLOOD ALT-8 AST-14 AlkPhos-73 TotBili-0.2 LACTATE ___ 12: 58AM BLOOD Lactate-1.8 ___ 04: 42AM BLOOD Lactate-0.8 MICROBIOLOGY ___ 12: 45 am BLOOD CULTURE **FINAL REPORT ___ Blood Culture, Routine (Final ___: NO GROWTH. _________________________________________________________ ___ 2: 00 am BLOOD CULTURE **FINAL REPORT ___ Blood Culture, Routine (Final ___: NO GROWTH. _________________________________________________________ ___ 8: 25 am FLUID,OTHER Site: PELVIS PELVIC FLUID COLLECTION. AEROBIC & ANAEROBIC CULTURE ADDED PER ___ ___. **FINAL REPORT ___ GRAM STAIN (Final ___: 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. FLUID CULTURE (Final ___: NO GROWTH. ANAEROBIC CULTURE (Final ___: NO GROWTH. SPECIMEN(S) SUBMITTED: BODY FLUID, abscess fluid DIAGNOSIS: Pelvic fluid collection: NEGATIVE FOR MALIGNANT CELLS. - Abundant neutrophils, histiocytes and debris; consistent with abscess fluid. --======== RELEVANT IMAGING: --======== Final Report EXAMINATION: CHEST (PA AND LAT) PORT ___ INDICATION: ___ with abd pain, post op// r/o free air TECHNIQUE: Chest PA and lateral COMPARISON: Radiograph from ___, CT from ___ FINDINGS: Lungs are clear without focal consolidation, pleural effusion, or pneumothorax. Mediastinal and hilar contours are within normal limits. Heart size is normal. No evidence of free air under the diaphragm. IMPRESSION: No evidence of pneumoperitoneum. _____________________________________ Final Report EXAMINATION: CT ABD AND PELVIS WITH CONTRAST ___ INDICATION: ___ with abd painNO_PO contrast// eval for sbo TECHNIQUE: Single phase contrast: MDCT axial images were acquired through the abdomen and pelvis following intravenous contrast administration. Oral contrast was not administered. Coronal and sagittal reformations were performed and reviewed on PACS. DOSE: Acquisition sequence: 1) Stationary Acquisition 4.5 s, 0.5 cm; CTDIvol = 21.7 mGy (Body) DLP = 10.8 mGy-cm. 2) Spiral Acquisition 5.9 s, 46.6 cm; CTDIvol = 11.6 mGy (Body) DLP = 538.6 mGy-cm. Total DLP (Body) = 549 mGy-cm. COMPARISON: None. FINDINGS: LOWER CHEST: Visualized lung fields are within normal limits. There is no evidence of pleural or pericardial effusion. ABDOMEN: HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout. There is no evidence of focal lesions. There is no evidence of intrahepatic or extrahepatic biliary dilatation. The gallbladder is within normal limits. PANCREAS: The pancreas has normal attenuation throughout, without evidence of focal lesions or pancreatic ductal dilatation. There is no peripancreatic stranding. SPLEEN: The spleen shows normal size and attenuation throughout, without evidence of focal lesions. ADRENALS: The right and left adrenal glands are normal in size and shape. URINARY: The kidneys are of normal and symmetric size with normal nephrogram. There is no evidence of focal renal lesions or hydronephrosis. There is no perinephric abnormality. GASTROINTESTINAL: The stomach is unremarkable. There are multiple dilated loops of small bowel in the lower abdomen and pelvis. The mid pelvis there is a loop which demonstrates fecalization with a transition to decompressed bowel, concerning for small bowel obstruction (2; 67). Posterior to this loop there is a 7.4 x 6.9 cm fluid collection which demonstrates rim enhancement, in the region of unknown on prior peritoneal inclusion cysts (2; 65). An additional left-sided multiloculated fluid collection is seen measuring 2.6 x 4.7 cm (2; 62). There is mild mesenteric soft tissue stranding in the pelvis. There is evidence of prior rectal surgery. The appendix is surgically absent. PELVIS: The urinary bladder and distal ureters are unremarkable. There is no free fluid in the pelvis. REPRODUCTIVE ORGANS: The uterus and bilateral ovaries are surgically absent. LYMPH NODES: There are multiple prominent retroperitoneal lymph nodes which do not meet the CT size criteria for lymphadenopathy. There is no pelvic or inguinal lymphadenopathy. VASCULAR: There is no abdominal aortic aneurysm. No atherosclerotic disease is noted. BONES: There is no evidence of worrisome osseous lesions or acute fracture. SOFT TISSUES: An umbilical hernia containing fat is noted. IMPRESSION: 1. Multiple dilated loops of small bowel with distal fecalization concerning for at least partial small bowel obstruction with mild surrounding fat stranding. 2. Two rim enhancing pelvic fluid collections which could represent residual peritoneal inclusion cysts. Superimposed infection cannot be excluded by imaging. ______________________________________ Final Report EXAMINATION: CT-GUIDED DRAINAGE ___ INDICATION: ___ yo G1P1 w/ stage IV rectal adenocarcinoma on capecitabine s/p laparoscopic extensive enterolysis, LOA, b/l ureterolysis, TLH-BSO, cystoscopy and rigid proctoscopy on ___ admitted with SBO + pelvic fluid collections.// Pelvic fluid collections amenable to drainage? COMPARISON: CT abdomen and pelvis ___ PROCEDURE: CT-guided drainage of a pelvic fluid collection. OPERATORS: Dr. ___, radiology trainee and Dr. ___, attending radiologist. Dr. ___ supervised the trainee during the key components of the procedure and reviewed and agrees with the trainee's findings. TECHNIQUE: The risks, benefits, and alternatives of the procedure were explained to the patient. After a detailed discussion, informed written consent was obtained. A pre-procedure timeout using three patient identifiers was performed per ___ protocol. The patient was placed in a prone position on the CT scan table. Limited preprocedure CT scan was performed to localize the collection. Based on the CT findings an appropriate skin entry site for the drain placement was chosen. The site was marked. Local anesthesia was administered with 1% Lidocaine solution. Using intermittent CT fluoroscopic guidance, an 18-G ___ needle was inserted into the collection. A sample of fluid was aspirated, confirming needle position within the collection. 0.038 ___ wire was placed through the needle and needle was removed. This was followed by placement of ___ Exodus pigtail catheter into the collection. The plastic stiffener and the wire were removed. The pigtail was deployed. The position of the pigtail was confirmed within the collection via CT fluoroscopy. Approximately 20 cc of serosanguineous fluid was aspirated with a sample sent for microbiology evaluation. The catheter was secured by a StatLock. The catheter was attached to suction bulb. Sterile dressing was applied. The procedure was tolerated well, and there were no immediate post-procedural complications. DOSE: Total DLP (Body) = 658 mGy-cm. SEDATION: Moderate sedation was provided by administering divided doses of 3 mg Versed and 200 mcg fentanyl throughout the total intra-service time of 35 minutes during which patient's hemodynamic parameters were continuously monitored by an independent trained radiology nurse. FINDINGS: 1. Limited preprocedure CT shows a dominant pelvic fluid collection that measures up to 7 cm, which was targeted for CT-guided drainage catheter placement. Postprocedure imaging shows appropriate catheter placement, with significant decrease in size of the collection. 2. Smaller more superiorly located left presacral collection appeared multiloculated on the prior CT, and measures approximately 4.3 x 2.9 cm. IMPRESSION: Successful CT-guided placement of an ___ pigtail catheter into the dominant pelvic collection. Samples were sent for microbiology and cytopathology evaluation. <MEDICATIONS ON ADMISSION> - Capecitabine 1000mg BID x2 weeks, 1 week off - Enoxaparin Sodium 70 mg SC BID - Colace - Tylenol <DISCHARGE MEDICATIONS> 1. Ciprofloxacin HCl 500 mg PO/NG Q12H RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth twice a day Disp #*6 Tablet Refills: *0 2. Docusate Sodium 100 mg PO BID Hold for loose bowel movements. RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day Disp #*60 Capsule Refills: *2 3. MetroNIDAZOLE 500 mg PO TID RX *metronidazole 500 mg 1 tablet(s) by mouth three times a day Disp #*9 Tablet Refills: *0 4. Milk of Magnesia 30 mL PO DAILY Duration: 1 Dose Hold for loose bowel movements. RX *magnesium hydroxide 400 mg/5 mL 30 mL by mouth once a day Disp #*1 Bottle Refills: *0 5. Senna 8.6 mg PO DAILY Hold for loose bowel movements. RX *sennosides [senna] 8.6 mg 2 tablets by mouth at bedtime Disp #*60 Tablet Refills: *2 6. Acetaminophen 1000 mg PO Q6H: PRN Pain - Mild/Fever 7. Enoxaparin Sodium 70 mg SC Q12H 8. Ibuprofen 600 mg PO Q8H <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> small bowel obctruction pelvic fluid collections <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Dear Ms. ___, You were admitted to the gynecology oncology service for a small bowel obstruction. You were conservatively managed. You were made n.p.o. Your nausea was treated with antiemetics. Your imaging showed a fluid collection in the pelvis concerning for an infection. The collection was drained by Interventional Radiology. A drain was left in place, and you were treated with IV antibiotics. Labs were done which showed no signs of systemic infection. You remained afebrile with stable vital signs and monitored closely for resolution of symptoms. When signs of return of bowel function were present your diet was advanced without incident and you are discharged home on a low residual diet. Your home medications were continued. You have recovered well and the team now feels it is safe for you to be discharged home. Please follow these instructions: * Take your medications as prescribed. We recommend you take non-narcotics (i.e. Tylenol, ibuprofen, and use the narcotic as needed for breakthrough pain. 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, Milk of Magnesia, and Senna. * 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. * You may eat a regular diet.
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Ms. ___ was admitted to the GYN Oncology service with an SBO and pelvic fluid collections observed on imaging. *)SBO Her SBO was conservatively managed with bowel rest. As her exam remained stable without peritoneal signs and she had no further episodes of emesis after admission, placement of a nasogastric tube was deferred. She remained NPO with maintenance fluids ___. On ___, she was advanced to sips without difficulty. On ___, she began to pass flatus and was advanced to a regular diet without issue. She was started on an aggressive bowel regimen and had multiple formed bowel movements on ___. *) Pelvic fluid collections On CT abdomen/ pelvis on ___, two rim enhancing pelvic fluid collections were observed measuring 7.4 x 9 cm and 2.6 x 4.7cm respectively, concerning for residual peritoneal inclusion cysts vs. superimposed abdominal infection. Given the proximity of the dominant fluid collection to the transition point of her SBO, there was further concern that the dominant fluid collection may be exerting mass effect which contributed to her SBO. She was started on broad spectrum empiric antibiotic therapy for presumed pelvic abscess with IV cefepime/Flagyl (___). She underwent ___ drainage of the dominant pelvic fluid collection on ___ with aspiration of 20 cc of serosanguinous fluid and placement of a left gluteal pigtail drain. Gram staining of the fluid aspirate was negative for microorganisms, and her aspirate cultures had no growth. On ___, there was minimal serosanguinous output from her drain, and the pigtail was removed. She was transitioned to PO ciprofloxacin/Flagyl on ___ to complete a 7 day total course of antibiotics. *)Low grade stage IV rectal adenocarcinoma: metastatic to the liver and lung She was maintained on her outpatient chemotherapy regimen of capecitabine 1000mg BID x2 weeks, 1 week off without interruption. *) Left upper extremity DVT, history of PE She was treated with prophylactic subcutaneous heparin on ___ in preparation for her ___ procedure. After her procedure, she resumed her therapeutic Lovenox at 70 mg BID on ___. On ___, she was tolerating a regular diet. She continued to pass flatus and bowel movements and had a normal abdominal exam. She was discharged home in stable condition with outpatient follow up.
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10981539-DS-21
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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> IV magnesium sulfate administration <HISTORY OF PRESENT ILLNESS> ___ year old G1P0 at ___ who was seen in OB Triage earlier for pre-term contractions and later returned with recurrent contractions. While in triage earlier, she was evaluated and found to be closed and 60% effaced. Her FFN was positive and a cervical length was 3 cm. She received one dose of terbutaline with some improvement in her symptoms. However, her contractions worsened this evening around 10 ___ such that they awoke her from sleep. She denies any fever, chills, N/V, dysuria, VB or LOF. +AFM. <PAST MEDICAL HISTORY> fibroids multiple sclerosis depression eye surgery <SOCIAL HISTORY> ___ <FAMILY HISTORY> non-contributory <PHYSICAL EXAM> On admission: T: 97.6 BP: 124/79 HR: 96 RR: 18 General: NAD Abd: gravid, non-tender, no guarding and no rebound SVE: ___ <PERTINENT RESULTS> ___ WBC-9.7 Hgb-11.7 Hct-34.1 Plt ___ . ___ URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-SM RBC-1 WBC-3 Bacteri-NONE Yeast-NONE Epi-10 <MEDICATIONS ON ADMISSION> Effexor PNV <DISCHARGE MEDICATIONS> no new medications prescribed <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> pre-term labor <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Continue on bedrest at home. Call for contractions that are painful and regular, leaking fluid, vaginal bleeding, or decreased fetal movement or if you have any other questions or concerns.
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*) Pre-term Contractions On re-evaluation Ms. ___ was thought to make cervical change from fingertip dilated to a more dilated cervical exam, and continued to have uncomfortable contractions. She was admitted for observation and betamethasone administration, and was given IV magnesium sulfate for tocolysis until steroid complete. Her contractions improved, and on re-examination her cervix was overall unchanged at fingertip dilated. Magnesium sulfate was discontinued when the course of steroids was complete, with overall improvement of her contractions. Fetal testing was reassuring throughout her hospitalization. She was discharged home on hospital day #4.
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| 130
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10981975-DS-7
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Monistat 1 / Sprintec (28) / Amoxicillin / Iodine / Betadine <ATTENDING> ___. <CHIEF COMPLAINT> bleeding <MAJOR SURGICAL OR INVASIVE PROCEDURE> dilation and curettage <HISTORY OF PRESENT ILLNESS> ___ s/p SVD of di di twins on ___ c/b manual extraction of placenta (total EBL 600), transferred from ___ for further evaluation of vaginal bleeding. Patient reports light bleeding since delivery, however last night after pumping, she pass several large clots and had a few "gushes" of blood. Bleeding has slowed since arrival to ___ ED. Reports lower abdominal cramping. No F/C/dizziness/SOB/CP/vaginal discharge/dysuria <PAST MEDICAL HISTORY> OB-GYN Hx: G1P1. IVF pregnancy. Hx of infertility and endometriosis. Remote hx of abnl pap, normal since then. Hx of HSV. PMH: perioral dermatitis; chronic dry eyes; hx childhood innocent heart murmur, negative echo in the past PSH: LSC for endometriosis; HSC for polyp; bunionectomy x 2, wisdom teeth <SOCIAL HISTORY> ___ <FAMILY HISTORY> noncontributory <PHYSICAL EXAM> On day of discharge: Afebrile, Vital signs stable gen: NAD cv: RRR pulm: CTAB abd: soft, nt, nd GU: minimal bleeding on pad ___: nt, no edema <PERTINENT RESULTS> ___ 12: 50PM BLOOD WBC-17.4* RBC-2.58* Hgb-8.2* Hct-25.9* MCV-101* MCH-32.0 MCHC-31.8 RDW-16.5* Plt ___ ___ 03: 54AM BLOOD WBC-11.8* RBC-2.38* Hgb-7.6* Hct-23.3* MCV-98 MCH-31.8 MCHC-32.5 RDW-15.3 Plt ___ ___ 03: 54AM BLOOD Neuts-71.1* ___ Monos-5.0 Eos-1.7 Baso-0.5 ___ 03: 54AM BLOOD ___ PTT-28.2 ___ ___ 03: 54AM BLOOD Glucose-108* UreaN-16 Creat-0.7 Na-142 K-4.4 Cl-107 HCO3-22 AnGap-17 ___ 03: 55AM BLOOD Lactate-0.8 <MEDICATIONS ON ADMISSION> ibuprofen <DISCHARGE MEDICATIONS> 1. Docusate Sodium 100 mg PO BID: PRN Constipation 2. Ibuprofen 600 mg PO Q6H: PRN pain 3. Oxycodone-Acetaminophen (5mg-325mg) ___ TAB PO Q4H: PRN Pain <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> retained products of conception postpartum hemorrhage <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> see instruction sheet from postpartum discharge pelvic rest for 6wks
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Ms. ___ was admitted to the postpartum service for vaginal bleeding. She underwent dilation and currettage for retained products of conceptions. Please see operative report for further details. She was discharged on POD#0 ambulating, voiding, with well controlled pain and minimal bleeding.
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10984447-DS-18
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> bleeding <MAJOR SURGICAL OR INVASIVE PROCEDURE> blood transfusion, exploratory laparotomy, total abdominal hysterectomy, bilateral salpingo-oophorectomy, pelvic lymphadenectomy <HISTORY OF PRESENT ILLNESS> This is a ___ who presents to the ED with heavy vaginal bleeding, dizziness and weakness. Denies CP, palpitations, LOC, falls, SOB, f/c/n/v/d/c. She reports that she has had abnormal uterine bleeding since ___. A pelvic ultrasound showed an enlarged right ovarian cyst and multifibroid uterus. In ___ she underwent a right ovarian cystectomy via ___ incision at ___ ___, there was no further assessment of her abnormal bleeding done at that point. She then continued to abnormal bleeding until ___, when she presented for infertility w/u to a gynecologist. She was again noted to have uterine fibroids and an endometrial biopsy was performed and returned with a grade 1 endometrioid endometrial adenocarcinoma. A hysterectomy was recommended. She declined that recommendation and pursued a number of alternative therapies. She then presented to Dr. ___ Gyn ___ for assessment of the success of her alternative therapies. Pelvic ultrasound on ___ showed: The uterus is anteverted. The uterus is enlarged, the myometrium is heterogeneous, with no focal masses and measures 15.6 x 9.4 x 13.6 cm. The endometrium is thickened, heterogenous, has internal vascularity and measures 32 mm. The left ovary is normal. In the right ovary a complex cyst with layering debris, no internal vascularity measures 6.3 x 4.8 x 4.7 cm. There is no free fluid. She then underwent a H&C D&C with intra-operative ultrasound concerning for invasive cancer. Pathology showed endometrial adenocarcinoma endometrioid type FIGO grade 1 of 3 in a background of EIN. Given her age and lack of clear risk factors, lynch staining was done and was not suggestive of lynch syndrome. She was again recommended to undergo TAH, BSO, staging and declined. She presents today with several days of significantly worsened vaginal bleeding. She has been wearing depends as her bleeding is too heavy for pads. She has been sitting on the toilet during bleeding episodes and notes copious blood and clots the bowl. She reports that this bleeding is very distressing to her and she is scared of dying and now ready to accept hysterectomy. She is adamant in her desire that no normal structures are removed and is still hesitant about any surgery in addition to hysterectomy. She is also concerned about any additional pre-operative imaging. She denies recent weight changes, chest pain, shortness of breath, abnormal discharge, nausea, vomiting, changes in bowel or bladder habits. ROS: Otherwise 10 point review of systems is negative except as above. <PAST MEDICAL HISTORY> PAST MEDICAL HISTORY: Endometrial cancer. Denies any history of asthma, heart disease, diabetes, high blood pressure, blood clots or cancer. HEALTH MAINTENANCE: Last mammogram in ___ reportedly within normal limits. Last colonoscopy in ___ within normal limits. She has never had a bone density scan. PAST SURGICAL HISTORY: ___, right ovarian cystectomy via ___ incision at ___. OBSTETRIC HISTORY: Gravida 1, para 0, TAB in ___. GYNECOLOGIC HISTORY: Last menstrual period ___ as described in the HPI, very irregular bleeding for the last two to ___ years. She has a known history of uterine fibroids. Her last Pap smear was in the ___ and was reportedly normal. She denies current sexual activity. She does not use any birth control. She does have a history of using birth control for approximately ___ years in the past. <SOCIAL HISTORY> The patient denies any history of smoking, alcohol use or other recreational drugs. She is working outside the home. She is single, but does live with her friend and partner who accompanies her today. She does feel safe in her home. She reports a history of verbal abuse in the past. <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> ___ 01: 03AM BLOOD WBC-9.4 RBC-2.01* Hgb-6.2* Hct-20.7* MCV-103* MCH-30.8 MCHC-30.0* RDW-21.1* RDWSD-79.7* Plt ___ ___ 12: 50PM BLOOD WBC-11.8* RBC-2.26* Hgb-7.1* Hct-23.1* MCV-102* MCH-31.4 MCHC-30.7* RDW-20.5* RDWSD-78.0* Plt ___ ___ 07: 05AM BLOOD WBC-5.8# RBC-2.04* Hgb-6.3* Hct-21.2* MCV-104* MCH-30.9 MCHC-29.7* RDW-20.8* RDWSD-79.2* Plt ___ ___ 09: 00AM BLOOD WBC-9.8# RBC-3.44*# Hgb-10.2*# Hct-32.5*# MCV-95# MCH-29.7 MCHC-31.4* RDW-23.4* RDWSD-78.3* Plt ___ ___ 06: 50AM BLOOD WBC-16.3*# RBC-2.76* Hgb-8.3* Hct-26.7* MCV-97 MCH-30.1 MCHC-31.1* RDW-22.1* RDWSD-77.8* Plt ___ ___ 06: 35AM BLOOD WBC-8.9 RBC-2.55* Hgb-7.7* Hct-24.8* MCV-97 MCH-30.2 MCHC-31.0* RDW-20.1* RDWSD-71.7* Plt ___ ___ 06: 25AM BLOOD WBC-5.2 RBC-2.71* Hgb-7.9* Hct-26.3* MCV-97 MCH-29.2 MCHC-30.0* RDW-19.0* RDWSD-67.0* Plt ___ ___ 01: 03AM BLOOD Neuts-85.1* Lymphs-9.5* Monos-4.7* Eos-0.1* Baso-0.3 Im ___ AbsNeut-8.01* AbsLymp-0.89* AbsMono-0.44 AbsEos-0.01* AbsBaso-0.03 ___ 01: 03AM BLOOD ___ PTT-23.7* ___ ___ 01: 03AM BLOOD Glucose-152* UreaN-13 Creat-0.7 Na-137 K-3.4 Cl-104 HCO3-26 AnGap-10 ___ 07: 05AM BLOOD Glucose-100 UreaN-7 Creat-0.6 Na-142 K-3.6 Cl-109* HCO3-26 AnGap-11 ___ 09: 00AM BLOOD Glucose-94 UreaN-5* Creat-0.7 Na-142 K-3.8 Cl-106 HCO3-26 AnGap-14 ___ 06: 50AM BLOOD Glucose-97 UreaN-8 Creat-0.7 Na-139 K-4.0 Cl-107 HCO3-25 AnGap-11 ___ 06: 35AM BLOOD Glucose-81 UreaN-6 Creat-0.6 Na-139 K-3.6 Cl-108 HCO3-27 AnGap-8 ___ 06: 25AM BLOOD Glucose-95 UreaN-6 Creat-0.5 Na-141 K-3.9 Cl-111* HCO3-23 AnGap-11 ___ 07: 05AM BLOOD Calcium-8.2* Phos-4.1 Mg-2.0 ___ 09: 00AM BLOOD Calcium-8.8 Phos-3.7 Mg-2.0 ___ 06: 50AM BLOOD Calcium-7.9* Phos-5.9*# Mg-1.7 ___ 06: 35AM BLOOD Calcium-7.9* Phos-3.3# Mg-1.9 ___ 06: 25AM BLOOD Calcium-8.2* Phos-3.4 Mg-1.9 ___ 04: 45AM URINE Color-Yellow Appear-Clear Sp ___ ___ 04: 45AM URINE Blood-LG Nitrite-NEG Protein-30 Glucose-NEG Ketone-40 Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-SM ___ 04: 45AM URINE RBC-94* WBC-9* Bacteri-FEW Yeast-NONE Epi-1 . ___ 4: 45 am URINE UCU ADDED TO ___. **FINAL REPORT ___ URINE CULTURE (Final ___: MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION. . ___ CT ABD & PELVIS W & W/O IMPRESSION: 1. Thickened and heterogeneous endometrium is consistent with history of endometrial cancer. Enlarged fibroid uterus. 2. Large right ovarian cyst is stable in size compared to ultrasound from ___. Smaller left ovarian cyst is also stable. 3. No evidence of metastasis is identified. . ___ CT CHEST W/CONTRAST IMPRESSION: No evidence of metastatic disease to the thorax. <MEDICATIONS ON ADMISSION> 1. Multivitamins. 2. Flaxseed oil. 3. Liquid chlorophyll. 4. Enzymes. 5. Probiotic. <DISCHARGE MEDICATIONS> 1. Acetaminophen ___ mg PO Q6H: PRN pain do not take more than 4000mg total 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 RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day Disp #*50 Capsule Refills: *2 3. Enoxaparin Sodium 40 mg SC DAILY Start: ___, First Dose: Next Routine Administration Time please take for 4 weeks RX *enoxaparin 40 mg/0.4 mL 40 mg SC DAILY Disp #*30 Syringe Refills: *0 4. 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 5. Multivitamins 1 TAB PO DAILY 6. OxycoDONE (Immediate Release) ___ mg PO Q4H: PRN Pain may cause drowsiness, do not drive while taking RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours Disp #*20 Tablet Refills: *0 <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> endometrial cancer <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Dear Ms. ___ . You were admitted to the gynecologic oncology service after undergoing the procedures listed below. You have recovered well after your operation, and the team feels that you are safe to be discharged home. Please follow these instructions: . 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. * 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 ___. . 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 initially for acute blood loss anemia. She had heavy vaginal bleeding with hematocrit decreased to 20 and received 2 units of packed red blood cells. Her hematocrit increased slightly but decreased again and did not have an overall appropriate response to the blood transfusion. She had a CT chest with no evidence of no metastatic disease, and a CT abdomen/pelvis with thickened endometrium, fibroid, stable ovarian cysts, and no evidence of metastasis. On hospital day 2, she had another episode of heavy vaginal bleeding and was transfused 3 more units of packed red blood cells. Her hematocrit responded appropriately and at this point, the patient agreed to surgical management for her endometrial cancer. On ___, she underwent total abdominal hysterectomy, bilateral salpingo-oophorectomy, and pelvic lymphadenectomy for endometrial cancer. Please see the operative report for full details. Her post-operative course is detailed as follows. Immediately postoperatively, her pain was controlled with epidural. Her diet was advanced without difficulty and she was transitioned to oral oxycodone, Tylenol, and ibuprofen. On post-operative day #1, her urine output was adequate so her Foley catheter was removed and she voided spontaneously. She received pneumo-boots, incentive spirometry, lovenox, and Colace for prophylaxis during her hospital stay. She was discharged home with prophylactic lovenox after teaching. She declined ___ services. 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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10985750-DS-10
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> ibuprofen <ATTENDING> ___. <CHIEF COMPLAINT> hematemesis <MAJOR SURGICAL OR INVASIVE PROCEDURE> none <HISTORY OF PRESENT ILLNESS> Ms. ___ is a ___ year-old G1 @ ___ with h/o GERD who presents for hematemesis. She has had persistent nausea/vomiting of pregnancy and believes that she has lost 10 pounds but isn't sure. Yesterday after eating a coconut, she started vomiting again with bright red blood and felt like something was stuck in her throat. Denies any fever/chills, sick contacts, or abdominal pain. Was feeling a little lightheaded yesterday but not today. Has not thrown up today, but is feeling very nauseous. No vaginal bleeding. Denies diarrhea but has not had a BM for ___ days. <PAST MEDICAL HISTORY> Prenatal care: -___: ___ by IVF dating -Labs: O+/Ab-/RPRNR/HIV-/HbSAg- *) Isses - Hemoglobin C trait - Fibroid uterus Obstetric History: G1 current Gynecologic History: endometriosis, infertility, fibroids <PAST MEDICAL HISTORY> GERD Past Surgical History: dx lsc ___ <SOCIAL HISTORY> ___ <FAMILY HISTORY> non-contributory <PHYSICAL EXAM> (on admission) Vitals in ED: 98.2 85 112/67 16 100% RA General: comfortable appearing, NAD CV: rate ___, normal rhythm Resp: CTAB Abd: soft, nondistended, nontender throughout Ext: no calf tenderness <PERTINENT RESULTS> ___ WBC-12.6 RBC-4.58 Hgb-12.4 Hct-34.3 MCV-75 Plt-288 ___ Neuts-71.1 ___ Monos-3.2 Eos-1.0 Baso-0.2 ___ Hct-30.5 ___ Hct-29.3 ___ Hct-29.6 ___ Hct-31.1 ___ BLOOD ___ PTT-30.2 ___ ___ BLOOD Glucose-90 UreaN-8 Creat-0.8 Na-136 K-4.1 Cl-101 HCO3-22 AnGap-17 ___ BLOOD Iron-66 calTIBC-326 Ferritn-48 TRF-251 ___ BLOOD ___ ___ URINE Blood-NEG Nitrite-NEG Protein-30 Glucose-NEG Ketone-80 Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-SM ___ URINE RBC-<1 WBC-2 Bacteri-MOD Yeast-NONE Epi-4 URINE CULTURE (Final ___: MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION <MEDICATIONS ON ADMISSION> prenatal vitamins <DISCHARGE MEDICATIONS> 1. Pantoprazole 40 mg PO Q12H Duration: 14 Days Take twice a day for one week then daily for one week. RX *pantoprazole 40 mg 1 tablet(s) by mouth daily Disp #*21 Tablet Refills: *0 2. Sucralfate 1 gm PO BID RX *sucralfate 1 gram/10 mL 10mL suspension(s) by mouth ___ x daily Refills: *1 3. Metoclopramide 10 mg PO BEFORE MEALS RX *metoclopramide HCl 10 mg 1 tab by mouth before meals up to 3x daily Disp #*30 Tablet Refills: *0 4. Ondansetron 4 mg PO Q8H: PRN nausea RX *ondansetron 4 mg 1 tablet(s) by mouth every 8 hrs Disp #*30 Tablet Refills: *0 <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> hematemesis hyperemesis gravidarum <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Dear Ms. ___, You were admitted to the hospital for observation after bleeding while vomiting. Per GI: take PPI BID x 1 week, then daily x 1 week In the morning, eat something bland and soft as soon as you wake, and take one tablet of ondansetron (zofran). Take metoclopramide (Reglan) just before eating with meals.
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___ y/o G1 with history of hyperemesis and GERD admitted at 10w2d with hematemesis. The GI team had evaluated her in the ED and recommended admission for observation and serial hematocrits. She was treated with IV fluids, antiemetics, and a PPI. She had no pregnancy concerns and had a reassuring ultrasound in radiology. She had no further episodes of hematemesis and her hematocrit was stable. She was discharged home and will have close outpatient followup.
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10985750-DS-11
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> ibuprofen <ATTENDING> ___. <CHIEF COMPLAINT> nausea/vomiting <MAJOR SURGICAL OR INVASIVE PROCEDURE> none <HISTORY OF PRESENT ILLNESS> ___ G1P0 @ 12w2d presenting with persistent nausea/vomiting for the past week. She reports ___ episodes of emesis today. She has not been able to tolerate fluids. SHe has tried reglan, zofran, and compazine without relief. At her ob visit today, she was asked to present to gyn triage for admission. She was previously hospitalized on the antepartum unit with a GI consult for concern regarding hematemesis following vomiting and consumption of a rough edge of coconut, states she continues to spit dark brown mucous with her vomint but has not been taking her pantoprazole as instructed by GI because she does not like the liquid form. No bright red blood in her vomit. No VB, LOF, fever, chills, sick contacts or recent travel. ROS otherwise negative. <PAST MEDICAL HISTORY> PNC: -___: ___ by IVF dating -Labs: O+ *) Issues - IVF pregnancy - Hemoglobin C trait - Fibroid uterus Obstetric History: G1 current Gynecologic History: endometriosis, infertility, fibroids <PAST MEDICAL HISTORY> GERD Past Surgical History: dx lsc ___ <SOCIAL HISTORY> ___ <FAMILY HISTORY> non-contributory <PHYSICAL EXAM> (on admission) VS: 98.5 131/63 88 Gen: NAD, AxO Pulm: normal work of breathing Abd: Soft, NT, ND, no R/G Ext: no edema TAUS: Single live IUP with FHR 150 <PERTINENT RESULTS> ___ WBC-9.9 RBC-4.33 Hgb-12.2 Hct-31.9 MCV-74 Plt-263 ___ WBC-8.7 RBC-3.69 Hgb-10.3 Hct-27.6 MCV-75 Plt-240 ___ Glu-119 Creat-0.7 Na-134 K-3.4 Cl-101 HCO3-24 AnGap-12 ___ Glu-103 BUN-7 Cre-0.6 Na-136 K-3.7 Cl-104 HCO3-23 ___ Glu-88 BUN-10 Cre-0.6 Na-133 K-3.7 Cl-101 HCO3-22 ___ Glu-116 BUN-4 Cre-0.6 Na-133 K-4.0 Cl-102 HCO3-20 ___ Glu-89 BUN-9 Cre-0.5 Na-133 K-3.9 Cl-101 HCO3-23 ___ ALT-5 AST-13 Amylase-62 Lipase-76 ___ Calcium-9.4 Phos-3.3 Mg-2.0 ___ Calcium-9.2 Phos-3.7 Mg-1.7 ___ Calcium-8.5 Phos-3.0 Mg-1.6 ___ Calcium-9.7 Phos-3.7 Mg-1.6 ___ 07: 29PM BLOOD TSH-0.25 ___ BLOOD HBsAg-NEGATIVE ___ URINE Blood-NEG Nitrite-NEG Protein-30 Glucose-300 Ketone-TR Bilirub-NEG Urobiln-2 pH-6.0 Leuks-TR ___ URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.5 Leuks-NEG Chlamydia trachomatis, Nucleic Acid Probe, with Amplification (Final ___: Negative for Chlamydia trachomatis NEISSERIA GONORRHOEAE, NUCLEIC ACID PROBE, WITH AMPLIFICATION (Final ___: Negative for Neisseria gonorrhoeae RUBELLA IgG SEROLOGY (Final ___: POSITIVE BY EIA VARICELLA-ZOSTER IgG SEROLOGY (Final ___: POSITIVE BY EIA HELICOBACTER PYLORI ANTIBODY TEST (Final ___: EQUIVOCAL BY EIA. URINE CULTURE (Final ___: MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION <MEDICATIONS ON ADMISSION> PNV zofran prn nausea reglan before meals zantac 75mg daily colace twice daily vitamin B6 twice daily <DISCHARGE MEDICATIONS> 1. Prenatal Vitamins 1 TAB PO DAILY 2. Promethazine 12.5 mg PO Q6H RX *promethazine 12.5 mg 1 by mouth every six (6) hours Disp #*60 Tablet Refills: *3 3. Pyridoxine 25 mg PO Q8H RX *pyridoxine 25 mg 1 tablet(s) by mouth every eight (8) hours Disp #*60 Tablet Refills: *3 4. Sertraline 25 mg PO DAILY RX *sertraline 25 mg 1 tablet(s) by mouth qam Disp #*30 Tablet Refills: *6 5. PredniSONE 20 mg PO DAILY take for 3 days RX *prednisone 20 mg 1 tablet(s) by mouth once a day Disp #*3 Tablet Refills: *0 6. PredniSONE 10 mg PO DAILY Take for 3 days after taking 20mg tablets for 3 days RX *prednisone 10 mg 1 tablet(s) by mouth once a day Disp #*3 Tablet Refills: *0 7. PredniSONE 5 mg PO DAILY Take for 7 days after taking 10mg tablets for 3 days RX *prednisone 5 mg 1 tablet(s) by mouth once a day Disp #*7 Tablet Refills: *0 8. methylPREDNISolone 4 mg oral per taper instructions RX *methylprednisolone 4 mg ___ tablet(s) by mouth daily Disp #*70 Tablet Refills: *0 9. Pantoprazole 40 mg PO Q12H RX *pantoprazole 40 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills: *6 10. Ondansetron 4 mg PO Q6H: PRN nausea RX *ondansetron HCl 4 mg 1 tablet(s) by mouth every six (6) hours Disp #*60 Tablet Refills: *0 <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> hyperemesis <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Dear Ms. ___, You were admitted to the hospital with nausea and vomiting of pregnancy. Your symptoms have improved with IV fluids and anti-nausea medications. You are now safe to be discharged home. Please take medications as needed for your nausea. Small, frequent meals are recommended. Please follow steroid taper as directed. Please call Dr. ___ office with questions or concerns.
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___ yo G1P0 admitted to the antepartum floor at 12w2d for hyperemesis. She was treated with IV fluids, antiemetics, and protonix. Her electrolytes were checked periodically and repleted as needed. A fetal heartrate was checked daily. Ms ___ would intermittently feel better and tolerate some fluids and food, however, her nausea and vomiting persisted and she was extremely anxious to go home. There was concern for depression and social services met with her to provide support. In addition, she agreed to start Zoloft after counseling. Given minimal improvement in her symptoms in almost 2 weeks, she agreed to try a course of steroids. Her symptoms improved and she was discharged home on ___. She will finish the steroid taper and followup at her next scheduled appointment.
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10986405-DS-20
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Penicillins <ATTENDING> ___. <CHIEF COMPLAINT> abdominal pain early pregnancy <MAJOR SURGICAL OR INVASIVE PROCEDURE> dilation and curettage (D&C) <HISTORY OF PRESENT ILLNESS> ___ ___ presents with sudden onset LAP. Pain started this morning, centrally located, associated with significant nausea and vomiting. Had been feeling in USOH until then. Had normal BM today and has been passing gas. Not associated with urinary pain, frequency, urgency. Denies F/C. Has presented to the ED on two other occasions with very similar pain. In ___ was evaluted by both GYN and general surgery, ultimately taken to OR for LSC appendectomy. Path demonstrated appendix with no inflammation. She presented again in ___ and an U/S and CT were normal. She was sent home with diagnosis of possible viral gastroenteritis. This pain is similar to prior episodes, although in past pain has been more lateralized. She says that her LMP was around ___, was shorter than usual, not heavy. Prior to that nl menses ___. She does note having usually very painful menses on day 1. She occ skips work, and pain meds otc usually help. She did have intercourse on ___ that was painful, w/ deep dyspareunia, resolved w/ cessation. She had a pelvic U/S here in ED, and did have pain throughout. <PAST MEDICAL HISTORY> Gyn History: #? Endometriosis: She received this diagnosis last ___. She recalls receiving a scan which showed a "thickened uterus" and being told by an ED doctor that she "likely has endometriosis." Nothing noted specifically on recent LSC. #Ovarian cysts: She was first diagnosed with this condition at the age of ___ in college. She recalls the cysts being diagnosed on imaging and being hospitalized for the condition. #Hx Metrorrhagia: reports abnormal periods last fall, but says recently they have been more regular. Menarche was ___. One abnormal pap smear; no colposcopy or excision. No STI Monogamous with one sexual partner for the last ___ years; uses condoms OBHx: G2P0 TAB Currently pregnant based on ED U/S <PAST MEDICAL HISTORY> Kidney stone ___ years ago Car accident in ___ Past Surgical History: D&C <SOCIAL HISTORY> ___ <FAMILY HISTORY> Non-contributory <PHYSICAL EXAM> O: T 97.5 HR 65 BP 117/60 O2 97% Appears unwell, thin Heart RRR, no m/r/g Lungs CTAB Abdomen soft, +BS, non-distended. Slightly TTP mid abdomen and increasingly tender moving to lower abdomen. More uncomfortable with palpation in suprapubic area and to left. Slight flank pain on palpation but not CVA. Speculum exam per ED resident: Normal vagina and cervix, no evidence of bleeding or abnormal discharge, cervical os closed. BME per ED: Adnexal TTP on left no CMT BME (by myself): Significant CMT leading to pt vomiting from pain during exam. Unable to examine adnexa fully secondary to discomfort. <PERTINENT RESULTS> ___ 06: 20AM BLOOD WBC-12.5* RBC-3.73* Hgb-11.9* Hct-35.0* MCV-94 MCH-31.8 MCHC-33.9 RDW-12.6 Plt ___ ___ 12: 10PM BLOOD WBC-10.2 RBC-4.48 Hgb-13.9 Hct-42.3 MCV-95 MCH-31.1 MCHC-32.9 RDW-12.9 Plt ___ ___ 06: 20AM BLOOD Neuts-80.1* Lymphs-15.3* Monos-4.4 Eos-0.1 Baso-0.1 ___ 12: 10PM BLOOD Neuts-79.6* Lymphs-17.6* Monos-2.4 Eos-0.2 Baso-0.2 ___ 12: 10PM BLOOD Glucose-130* UreaN-11 Creat-0.7 Na-139 K-3.8 Cl-103 HCO3-22 AnGap-18 ___ 12: 10PM BLOOD ___ <MEDICATIONS ON ADMISSION> none <DISCHARGE MEDICATIONS> 1. oxycodone 5 mg Capsule Sig: ___ Capsules PO every ___ hours as needed for pain. Disp: *20 Capsule(s)* Refills: *0* 2. acetaminophen 500 mg Tablet Sig: ___ Tablets PO Q6H (every 6 hours) as needed for pain. Tablet(s) 3. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day as needed for constipation. Disp: *60 Capsule(s)* Refills: *2* 4. Prenatal + DHA 28 mg iron- 975 mcg-200 mg Combo Pack Sig: One (1) PO once a day. Disp: *30 tab* Refills: *8* 5. ZOFRAN ODT 4 mg Tablet, Rapid Dissolve Sig: One (1) Tablet, Rapid Dissolve PO every eight (8) hours as needed for nausea. Disp: *20 Tablet, Rapid Dissolve(s)* Refills: *0* <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> abdominal pain pregnancy <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. You can take oxycodone and tylenol for pain. Do not take motrin, aleve, advil, or any other medications for pain. * Do not drive while taking narcotics. * Do not combine narcotic and sedative medications or alcohol * Do not take more than 4000mg acetaminophen (APAP) in 24 hrs * You may eat a regular diet To reach medical records to get the records from this hospitalization sent to your doctor at home, call ___.
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Ms. ___ was admitted with lower abdominal pain consistent with prior episodes of unk etiology and incidentally noted intrauterine pregnancy, likely nonviable. She was admitted for observation. She was initially afebrile but continued to have significant pain and nausea. On HD 2 she became febrile and was started on gentamicin and clindamycin, and the decision was made for D&C given that the patient was planning termination and was possibly now presenting with septic abortion. Please refer to operative note for full details. Post-operatively, she continued to have some pain but generally improved. She displayed some suspicious behavior suggestive of secondary gain of pain medications. She was afebrile for 24 hours. While preparing discharge documents including a prescription for doxycycline for ongoing treatment of septic abortion, the patient eloped against medical advice.
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| 177
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10987724-DS-5
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> cold temperature <ATTENDING> ___. <CHIEF COMPLAINT> Vaginal Bleeding, Endometrial adenocarcinoma <MAJOR SURGICAL OR INVASIVE PROCEDURE> Robotic-assisted total laparoscopic hysterectomy, bilateral salpingo-oophorectomy, bilateral pelvic lymphadenectomy, washings <HISTORY OF PRESENT ILLNESS> HPI: ___ G3P3 presented initially to the ED with new sudden onset of vaginal bleeding. At that time she denied any other hx of abnormal bleeding and has been postmenopausal since ___. She further denied recent wt changes, no night sweat, possibly mild abd bloating after eating, regular appetite and PO intake. Not sexually active. A pelvic US at that time showed: 6.9 x 6.0 x 8.5 cm uterus, an echogenic mass-like structure within the lower uterine segment endometrial canal, measuring 2.9 x 1.8 x 2.4 cm. This could represent a mass or a large thrombus. The endometrial canal is markedly widened and contains heterogeneous soft tissue and blood. The width of the endometrial canal measures up to 2.6 cm at the fundus. The bilateral ovaries appear normal. There is no pelvic free fluid. A subsequent EMB ___: Endometrial adenocarcinoma, endometrioid type. Due to fragmentation grade could not be fully assessed but architecture concerning for Grade 2 She presented to Dr ___ a RA TLH adn BSO was planned. <PAST MEDICAL HISTORY> Asthma Osteoarthritis Hypertension GERD <SOCIAL HISTORY> ___ <FAMILY HISTORY> -mother: leukemia at age ___ -maternal grandfather, 2 maternal aunts, and great aunt: colon cancer -maternal aunt: ? gyn cancer Denies history of cervical , uterine, ovarian, colon or breast cancers <PHYSICAL EXAM> On day of consultation: PHYSICAL EXAM ___ General: no acute distress, calm, comfortable Cardiac: RRR Pulm: CTA Abdomen: soft, non tender Pelvic: Normal external anatomy, atrophic changes, minimal old blood in the vaginal valut, no masses visualized, no visible cervical lesions. Bimanual: Difficult to complete due to body habitus and possibly retroverted uterus, some fullness is felt in the right pelvis, no evidence of a grossly enlarged uterus, no tenderness on exam On day of discharge: Gen: NAD, comfortable Cardiac: RRR Pulm: Diffuse wheezing bilaterally Abd: Soft, appropriatly tender. Incisons clean dry and intact GU: Minimal vaginal bleeding Ext: Nontender no edema <PERTINENT RESULTS> ___ 1: 00 AM CHEST (PA & LAT) FINDINGS: The lung volumes are low. There is both left and right basal atelectasis. Moreover, an area of band-like opacities has newly appeared in the right upper lobe. Given lower lung volumes, the hilar structures appear slightly larger than on the previous image. Minimal pneumoperitoneum of the laparoscopy, as manifested by some amount of infradiaphragmatic air. Normal size of the cardiac silhouette. No pneumothorax. No pulmonary edema. ___ 2: 04 ___ CTA CHEST W&W/O C&RECONS, NON- IMPRESSION: 1. No pulmonary embolus. 2. Unchanged marked enlargement of the main pulmonary artery ___ 04: 15AM BLOOD Glucose-132* UreaN-12 Creat-1.2* Na-142 K-3.9 Cl-106 HCO3-28 AnGap-12 ___ 02: 00AM BLOOD Glucose-109* UreaN-10 Creat-0.6 Na-139 K-3.4 Cl-103 HCO3-27 AnGap-12 ___ 06: 20AM BLOOD Glucose-94 UreaN-9 Creat-0.7 Na-140 K-3.7 Cl-99 HCO3-32 AnGap-13 ___ 02: 00AM BLOOD cTropnT-<0.01 ___ 08: 30PM BLOOD CK-MB-1 cTropnT-<0.01 <MEDICATIONS ON ADMISSION> The Preadmission Medication list is accurate and complete. 1. Amlodipine 5 mg PO DAILY 2. Hydrochlorothiazide 25 mg PO DAILY 3. Albuterol Inhaler ___ PUFF IH Q4H: PRN asthma 4. Tiotropium Bromide 1 CAP IH DAILY 5. Montelukast Sodium 10 mg PO DAILY 6. Alvesco (ciclesonide) 160 mcg/actuation Inhalation daily 7. Fluticasone Propionate NASAL 1 SPRY NU DAILY 8. celecoxib 200 mg Oral BID 9. azelastine 0.15 % (205.5 mcg) NU daily 10. DiphenhydrAMINE 25 mg PO DAILY 11. Loratadine 10 mg PO DAILY allergies <DISCHARGE MEDICATIONS> 1. Albuterol Inhaler ___ PUFF IH Q4H: PRN asthma 2. Amlodipine 5 mg PO DAILY 3. Fluticasone Propionate NASAL 1 SPRY NU DAILY 4. Hydrochlorothiazide 25 mg PO DAILY 5. Loratadine 10 mg PO DAILY allergies 6. Montelukast Sodium 10 mg PO DAILY 7. Tiotropium Bromide 1 CAP IH DAILY 8. Ibuprofen 600 mg PO Q6H: PRN pain take with food RX *ibuprofen 600 mg 1 tablet(s) by mouth Q6H: PRN Disp #*100 Tablet Refills: *1 9. Oxycodone-Acetaminophen (5mg-325mg) ___ TAB PO Q4H: PRN pain RX *oxycodone-acetaminophen 5 mg-325 mg ___ tablet(s) by mouth Q4H: PRN Disp #*50 Tablet Refills: *0 10. azelastine 0.15 % (205.5 mcg) NU daily 11. Alvesco (ciclesonide) 160 mcg/actuation Inhalation daily 12. celecoxib 200 mg Oral BID 13. DiphenhydrAMINE 25 mg PO DAILY 14. Docusate Sodium 100 mg PO BID take while using percocet RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day Disp #*100 Capsule Refills: *0 <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> endometrial cancer, final pathology pending* <DISCHARGE CONDITION> stable <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Dear Ms. ___, You were admitted to the gynecologic oncology service after undergoing the procedures listed below. You have recovered well after your operation, and the team feels that you are safe to be discharged home. Please follow these instructions: . Laparoscopic instructions: * Take your medications as prescribed. * Do not drive while taking narcotics. * Do not combine narcotic and sedative medications or alcohol * Do not take more than 4000mg acetaminophen (APAP) in 24 hrs * No strenuous activity until your post-op appointment * Nothing in the vagina (no tampons, no douching, no sex) for ___ weeks. * No heavy lifting of objects >10lbs for ___ weeks. * You may eat a regular diet . Incision care: * You may shower and allow soapy water to run over incision; no scrubbing of incision. No bath tubs for 6 weeks. * You 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 for a Robotic assisted total laproscopic hysterectomy, bilateral salpino oopherectomy, with pelvic lymph node dissection. Please see the operative report for full details. Her post-operative course is detailed as follows. Immediately postoperatively, her pain was controlled with Iv dilaudid and tylenol. On post-operative day #1, her urine output was inadequate so her Foley catheter was was not removed and her creatinine was found to be elevated at 1.2. She was given an IV fluid bolus and on POD#2 her creatinine had decreased back to normal range at 0.6 and foley was removed. Her diet was advanced slowly and she was transitioned to PO percocet and motrin. On POD#2 she was desaturating to 86% while sleeping but this resolved when woken up. Chest x ray at that time revealed atlectasisn and left lobe emphysema. Her O2 saturation dropped once again but EGK did not reveal any abnormalities, cardiac enzymes were normal and a CTA did not demonstrate any PE or pulmonary edema. Increased ambulation was encouraged. 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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| 294
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10987724-DS-6
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> cold temperature <ATTENDING> ___. <CHIEF COMPLAINT> intractable nausea, vomiting <MAJOR SURGICAL OR INVASIVE PROCEDURE> Exploratory laparoscopy, reduction of small bowel herniation and repair of laparoscopic port site fascial defect <HISTORY OF PRESENT ILLNESS> ___ G3P3 POD3 from RA-TLH, BSO, PLND for endometrial cancer, now with intractable nausea/vomiting that started today. She has vomited 5x's today, large volume brownish liquid. She has been taking small sips, but this worsens her nausea. She denies hematemsis, burping. Of note, she was discharged today in good condition. She states that prior to discharge, she was feeling "queasy," but nothing of this nature. She has taken one percocet today, and she had been taking percocet prior to discharge without nausea. She is having some abdominal soreness, but denies severe abdominal pain. She has not had a BM, but has been passing flatus throughout the day. Denies diarrhea, fever, difficulty urinating. Her surgery was uncomplicated and without significant bowel manipulation. During her evaluation in GYN triage, she proceeded to have ~700cc bilious emesis. <PAST MEDICAL HISTORY> PObHx: G3P3, SVDx3, uncomplicated. PGynHx: Last Pap per pt was last yr wnl; last Pap wnl (documented in OMR ___. Remote hx abnormal Pap x1, f/u since then all negative. Denies history of STIs, gynecological diagnoses such a fibroids, endometriosis PMHx: HTN, asthma/COPD, OA, GERD PSH: recent R hip replacement, hx of IUD perforation and s/p LSC converted to exlap (via Pfannestiel skin incision) for removal, BTL <SOCIAL HISTORY> ___ <FAMILY HISTORY> -mother: leukemia at age ___ -maternal grandfather, 2 maternal aunts, and great aunt: colon cancer -maternal aunt: ? gyn cancer Denies history of cervical , uterine, ovarian, colon or breast cancers <PHYSICAL EXAM> Upon admission: 99.1 91 114/81 16 94RA -> 99RA after deep inspiration NAD, appears fatigued RRR CTAB Abd soft, mildly-moderately distended, tympanic to percussion throughout, appropriately TTP, no r/g, +BS Incisions c/d/i Ext no TTP, no edema Upon discharge: NAD, comfortable RRR CTAB Abd soft, nontender, nondistended BSx4, Incisions c/d/i Ext no TTP or edema <PERTINENT RESULTS> KUB ___: The visualized lung bases are unremarkable. There are scattered air and stool in non-distended loops of colon. There are several dilated small bowel loops with air-fluid levels on the upright study, which is concerning for a partial small-bowel obstruction. No free air is seen. An incompletely visualized right hip replacement is seen. Multiple calcifications in the pelvis likely represent phleboliths. Several more focal rounded opacities in the right mid and lower abdomen correspond to radiopaque ingested material on a CT study of ___. Mild degenerative changes are seen involving the lumbar spine and sacroiliac joints. IMPRESSION: 1. Dilated small bowel loops with air-fluid levels on the upright study suggestive of partial small-bowel obstruction. No evidence of free intraperitoneal air. CT ABD/Pelvis ___: CT ABDOMEN: The stomach and small bowel are dilated and fluid-filled up until a transition point in the left lower quadrant where a short segment of small bowel herniates through the abdominal wall (2: 55,62,300). The small bowel distal to this is decompressed. There is a small amount of free fluid in the presacral space, which may be post-surgical. Subcutaneous air is seen throughout the subcutaneous tissues of the abdominal wall, presumably from recent laparoscopic surgery. There is also fluid between the left internal oblique and transversus abdominis muscles, likely post-surgical (2: 36). There is plate-like atelectasis in the right lower lobe. The lung bases are otherwise clear. The visualized portions of the heart and pericardium are remarkable only for mitral annular calcifications. The liver enhances homogenously, and there is no focal liver lesion. Dependent hyperdense material in the gallbladder more likely represents vicarious excretion of IV contrast from recent CTA chest. The hepatic and portal veins are patent. The pancreas, spleen, and adrenals are normal. Some fluid is now present near the splenic hilum. The kidneys enhance symmetrically and excrete contrast without evidence of hydronephrosis or mass. Multiple subcentimeter hypodensities are too small to characterize. There is also a 19-mm simple cyst in the left kidney, previously characterized on ultrasound. CT PELVIS: The appendix is normal is (300: 12). Aside from stool in the cecum, the colon is decompressed. The rectum and urinary bladder are normal. The patient has undergone hysterectomy and bilateral salpingo-oophorectomy. OSSEOUS STRUCTURES: There right total hip arthroplasty is intact. IMPRESSION: 1. Small bowel obstruction with transition point through an abdominal wall defect in the left lower quadrant. 2. Post-surgical changes from recent laparoscopic surgery including fluid between the layers of the abdominal wall in the left side of the abdomen. <MEDICATIONS ON ADMISSION> The Preadmission Medication list is accurate and complete. 1. Amlodipine 5 mg PO DAILY 2. Hydrochlorothiazide 25 mg PO DAILY <DISCHARGE MEDICATIONS> 1. Amlodipine 5 mg PO DAILY 2. Hydrochlorothiazide 25 mg PO DAILY <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> Small bowel obstruction status post laparoscopic hysterectomy <DISCHARGE CONDITION> Level of Consciousness: Alert and interactive. Mental Status: Clear and coherent. 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: . Laparoscopic instructions: * Take your medications as prescribed. * Do not drive while taking narcotics. * Do not combine narcotic and sedative medications or alcohol * Do not take more than 4000mg acetaminophen (APAP) in 24 hrs * No strenuous activity until your post-op appointment * Nothing in the vagina (no tampons, no douching, no sex) for ___ weeks. * No heavy lifting of objects >10lbs for ___ weeks. * ___ may eat a regular diet 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 ___ have steri-strips, leave them 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. . 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 Robotic assisted total laproscopic hysterectomy, bilateral salpingo oopherectomy with pelvic lymph node dissection. On the day of discharge, she was readmitted due to nausea and vomitting. Her imaging studies were consistent with a small bowel obstruction. She therefore underwent a laparoscopic reduction and repair of a port site hernia. Please see the operative report for full details. Her post-operative course is detailed as follows. Immediately postoperatively, her pain was controlled with IV dilaudid and tylenol. On post-operative day #1, her urine output was adequate so her Foley catheter was removed and she voided spontaneously. Her diet was slowly advanced and she was transitioned to PO percocet and motrin. 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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10990267-DS-11
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___ <CHIEF COMPLAINT> Symptomatic fibroid uterus <MAJOR SURGICAL OR INVASIVE PROCEDURE> Total abdominal hysterectomy, bilateral salpingo-oophorectomy, trach evaluation <HISTORY OF PRESENT ILLNESS> This is a ___ gravida 2, para 2 (twins)/3 living children. Her last menstrual period was in ___. The patient and her daughter presented late for today's visit due to inclement weather conditions. She is accompanied by her daughter who is her caregiver. . The patient responds to questions, however, is limited with her ability to discuss her history. Her daughter brought a folder outlining events from ___. During that time, patient had a hemorrhagic stroke which resulted in a subarachnoid hemorrhage secondary to an aneurysm. At that time she was treated with a right craniotomy and clipping of her middle cerebral artery. This was done at ___ and records were provided. She has left hemiparesis and a trach and a PEG for her nutrition. . Please note, Ms. ___ was evaluated in ___ by Dr. ___ ___ who was a GYN oncologist working here at the ___ ___. She had been transported from ___ with heavy vaginal bleeding. At ___ ___, her hematocrit according to documentation in her medical records had gone as low as 7.6%. She was admitted to the intensive care unit given 7 units of packed red cells. She was then transported to the ___. On presentation at her hematocrit was 28%. Of note, on clinical exam, she had a pelvic abdominal mass that was approximately 4 fingerbreadths above the umbilicus. She has been scheduled for surgery on ___ for total abdominal hysterectomy bilateral salpingo-oophorectomy. . This surgery was postponed secondary to need for workup of her hematologic issues. It is now ___ years later the patient and daughter are requesting that surgery at this time. The patient had an ultrasound done on ___ at ___ that revealed a uterine fibroid which measured 19 x 12 x 18 cm that has replaced identifiable uterus. No endometrium could be identified. There is a question whether the left ovary visualized that was measured at 4 x 3 x 4.4 cm with actual ovary. This is also related to the heterogenous multiple fibroids and measurement may have been exophytic portion of a fibroid. Not certain whether either ovary was seen. There was no ascites. <PAST MEDICAL HISTORY> OB/GYN HISTORY: Menarche at 13. Menopause ___, two pregnancies, both spontaneous vaginal deliveries, first pregnancy termed infant, second pregnancy spontaneous vaginal delivery of twins at approximately 32 weeks. She has no history of abnormal Pap smears or sexually transmitted infections. . PAST MEDICAL HISTORY: Hemorrhagic stroke, aneurysm, left-sided hemiplegia, seizure disorder, hypertension, hypercholesterolemia, history of DVT/pulmonary embolism, depression, anxiety. . ALLERGIES: No known drug allergies. . OPERATIVE HISTORY: ___ right craniotomy status post clipping of right middle cerebral artery. A trach and PEG placement, left wrist schwannoma removed. <SOCIAL HISTORY> ___ <FAMILY HISTORY> Negative for any female cancers. <PHYSICAL EXAM> Discharge physical exam Vitals: VSS Gen: NAD, trach and PEG tubes in place CV: RRR Resp: no acute respiratory distress, able to speak with trach in place Abd: soft, appropriately tender, no rebound/guarding, incision c/d/i Ext: no TTP <PERTINENT RESULTS> ___ 03: 30PM BLOOD Type-ART Temp-36.1 Rates-/14 FiO2-98 pO2-122* pCO2-51* pH-7.38 calTCO2-31* Base XS-4 AADO2-530 REQ O2-88 Intubat-NOT INTUBA <MEDICATIONS ON ADMISSION> Albuterol, Xanax 0.25 mg BID PRN, amlodipine 10mg daily, atorvastation 20mg daily, citalopram 20mg daily, depakote 250mg TID, labetolol 300mg TID, Keppra 750mg BID, methimazole 5mg daily, omeprazole 20mg daily <DISCHARGE MEDICATIONS> 1. Albuterol 0.083% Neb Soln 1 NEB IH TID 2. Amlodipine 10 mg NG DAILY 3. Citalopram 20 mg NG DAILY 4. Docusate Sodium (Liquid) 100 mg PO BID RX *docusate sodium 50 mg/5 mL 100 mg by mouth twice a day Refills: *2 5. Labetalol 300 mg PO TID 6. LeVETiracetam Oral Solution 750 mg NG BID 7. Methimazole 5 mg NG DAILY 8. Omeprazole 20 mg PO DAILY 9. Acetaminophen (Liquid) 650 mg PO Q6H: PRN pain do not take more than 4000mg total per day RX *acetaminophen 650 mg/20.3 mL 650 mg by mouth every six (6) hours Refills: *1 10. Valproic Acid ___ mg NG Q8H 11. OxycoDONE Liquid 5 mg PO/NG Q4H: PRN pain do not drive while taking this medication RX *oxycodone 5 mg/5 mL 5 mg by mouth every four (4) hours Refills: *0 12. Sulfameth/Trimethoprim DS 1 TAB NG Q12H Duration: 3 Days RX *sulfamethoxazole-trimethoprim 800 mg-160 mg 1 tablet(s) by mouth every twelve (12) hours Disp #*5 Tablet Refills: *0 13. Ibuprofen 400 mg PO Q8H pain take with food RX *ibuprofen 400 mg 1 tablet(s) by mouth every eight (8) hours Disp #*50 Tablet Refills: *1 <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> Symptomatic fibroid uterus <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Bedbound. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Dear Ms. ___, You were admitted to the gynecology service after your procedure. You have recovered well and the team believes you are ready to be discharged home. You will need to take the oral antibiotic (Bactrim) for your urinary tract infection for 3 days (___). Please call Dr. ___ office with any questions or concerns. Please follow the instructions below. General instructions: * Take your medications as prescribed. * Take a stool softener such as colace 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 resume your regular diet. Incision care: * You may shower and allow soapy water to run over incision; no scrubbing of incision. No tub baths for 6 weeks. * If you have staples, they will be removed at your postoperative appointment. 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 abdominal hysterectomy, bilateral salpingo-oophorectomy, and trach evaluation for symptomatic fibroid uterus. Please see the operative report for full details. . Her post-operative course was uncomplicated. Immediately post-op, her pain was controlled with IV dilaudid and toradol. . On post-operative day 1, nutrition was consulted regarding her tubefeeds and she was advanced to goal without difficulty. She was transitioned to oral oxycodone, ibuprofen, and acetaminophen. On post-operative day 2, her urine output was adequate so her foley was removed and she voided spontaneously. On post-operative day 3, she had several episodes of urinary incontinence, and urinalysis was consistent with a urinary tract infection. She is treated with Bactrim, to be continued for 3 days. . By post-operative day 4, she was able to breath and speak with her trach tube, tolerating tubefeeds, voiding spontaneously, at baseline mobility, and pain was controlled with medications through her PEG tube. She was then discharged home in stable condition with ___ for staple removal and outpatient follow-up scheduled.
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10991710-DS-16
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> latex / peanut <ATTENDING> ___ <CHIEF COMPLAINT> Retained products of conception <MAJOR SURGICAL OR INVASIVE PROCEDURE> dilation and curettage <HISTORY OF PRESENT ILLNESS> ___ yo G1P0 woman who presented to the ED with vaginal discharge. She is s/p TAB at ___ wks with villi seen ___. She had spotting until ___ with mild RLQ soreness. ___, she reported gush of watery blood during shower lasting for 1hr. <PAST MEDICAL HISTORY> OBHx: - G1 TAB GynHx: - No history of LEEP or other cervical procedure - denies h/o abnl Pap, fibroids, Gyn surgery, STIs PMH: - Asthma, no hospitalizations PSH: - left knee surgery <SOCIAL HISTORY> ___ <FAMILY HISTORY> Non-contributory <PHYSICAL EXAM> Gen: A&Ox3, NAD CV: RRR Pulm: CTAB Abd: soft, nondistended, mild lower abd TTP, no rebound/guarding. no peritoneal signs Back: no costovertebral angle TTP Ext: no TTP or edema <PERTINENT RESULTS> ___ 06: 20AM BLOOD WBC-8.4 RBC-4.19 Hgb-12.4 Hct-36.4 MCV-87 MCH-29.6 MCHC-34.1 RDW-13.6 RDWSD-42.2 Plt ___ ___ 06: 20AM BLOOD Neuts-54.4 ___ Monos-9.4 Eos-0.7* Baso-0.2 Im ___ AbsNeut-4.58 AbsLymp-2.96 AbsMono-0.79 AbsEos-0.06 AbsBaso-0.02 ___ 06: 20AM BLOOD Plt ___ ___ 02: 45PM BLOOD Glucose-82 UreaN-11 Creat-0.8 Na-138 K-6.3* Cl-101 HCO3-21* AnGap-16 ___ 02: 45PM BLOOD HCG-___ MRI Pelvis There are markedly vascular retained products of conception, attached to the left posterior fundus, with associated increased vascularity of the adjacent myometrium, but no identified feeding artery or early draining vein to indicate an arteriovenous malformation. <MEDICATIONS ON ADMISSION> None <DISCHARGE MEDICATIONS> 1. Acetaminophen ___ mg PO Q6H: PRN Pain - Mild Do not take more than 4000mg in 24 hours 2. Ibuprofen 600 mg PO Q8H: PRN Pain - Mild <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> retained products of conception <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Dear Ms. ___, You were admitted to the gynecology service for retained products of conception. Review of your images with our imaging specialists was not concerning for a vascular malformation. You received intravenous antibiotics and underwent a dilation and curettage. Your team now feels you are safe to go home. Please call ___ office with any questions or concerns. Please follow the instructions below. General instructions: * 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. 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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Ms. ___ was admitted to GYN on ___ due to concern for retained products of conception versus arteriovenous malformation in the setting of recent D&C for TAB. At the time of admission, she was afebrile with a slightly elevated blood count and foul-smelling vaginal discharge. She received on dose of zosyn and was initiated on IV ampicillin/ gentamycin/ clindamycin. An MRI was obtained that did not show any evidence of an AVM. On ___, she underwent a D&C. Please see the operative report for full details. Her post-operative course was uncomplicated. Immediately post-op, her pain was controlled with oral pain medications. By post-operative day 0, she was tolerating a regular diet, voiding spontaneously, ambulating independently, and pain was controlled with oral medications. She was then discharged home in stable condition with outpatient follow-up scheduled.
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10994688-DS-20
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___ ___ Complaint: lower abd pain <MAJOR SURGICAL OR INVASIVE PROCEDURE> CT Chest/Abd/Pelvis <HISTORY OF PRESENT ILLNESS> ___ G1___ with a known R adnexal mass who was called in with persistent R sided pelvic pain radiating to her back. She states that she was first seen 2 weeks ago at ___, at which time she was complaining of flu-like illness though without any upper respiratory symptoms and only GI symptoms. She underwent a CT A/P for r/o appendicitis, and was diagnosed with a R ovarian cyst incidentally as well as colitis. She was noted to have a leukocytosis to 15 ___s thromcytosis to the 500s. Pt states that she has been told during a prior IVF work up ___ year prior that she has a cyst but does not remember the size. She then underwent a follow up TVUS, after which she started having R sided pelvic pain. She was discharged from ___ and started on Tamiflu though ultimately was tested negative for influenza. She continued to have malaise, flu-like symptoms, with intermittent high fevers and night sweats at home as well as nausea. She was seen by her PCP ___ ___ complaining of worsening R lower abdominal/pelvic pain radiating to her back, worsening with laying flat. She was then recommended to present to ___ for further evaluation. At ___, she was noted to have a Tmax of 99.5. Leukocytosis to 14.5. Cr was normal at 0.6. UA was negative. HCG was negative. She underwent a pelvic US which showed: IMPRESSION: 1. 10.8 cm cyst with diffuse low-level echoes in the right ovary, most compatible with an endometrioma. No evidence of active ovarian torsion, noting that intermittent or partial torsion cannot be excluded. 2. Normal uterus and left ovary. She also underwent a CT urogram which showed: IMPRESSION: 1. 11.1 x 9.3 cm thick-walled cystic mass in the mid pelvis, which may be arising from the right adnexa. This is not further characterized by CT. Differential considerations include an endometrioma, tubo-ovarian abscess, or epithelial tumor. Further evaluation with contrast enhanced MRI of the pelvis is recommended, as well as Gynecology consultation. 2. Mild right hydroureteronephrosis, to the level of the mid to distal ureter, secondary to compression by the cystic mass. 3. Inflammatory stranding about the proximal rectum, which appears tethered to the cystic mass. Given the imaging findings, she was sent to ___ ED on ___. Prior to transfer, she was given a dose of IV ceftriaxone for presumed UTI as well as IV morphine. Upon arrival to ___, she was noted to have significant improvement in her pain (4 hours after morphine). She was noted to have a benign abdominal and pelvic exam, with mild abdominal tenderness over the suprapubic region, fullness in the posterior cul-de-sac that was nontender to palpation. Of note, she was febrile to 101.6 in the ED and tested negative for influenza. She also had coags drawn which were notable for INR of 1.7. She was discharged home with plan for outpatient follow up for surgical planning. The patient called this afternoon stating that she has not been able to get comfortable since discharge from the ED. She had to sleep sitting up. She continues to complain of ___ pain. She has taken Tylenol once but has not continued due to nausea. She continues to have fevers at home. She was then called into triage. Upon arrival here, she continues to have pain and nausea, no vomiting. She denies any VB, abnormal discharge, CP/SOB, cough/cold symptoms, no dysuria. She has had some diarrhea. Her LMP was ___. She has not been sexually active. She continues to feel generally unwell and tired. <PAST MEDICAL HISTORY> OBHx: G1P0010 - G1: TAB (D&C) GynHx: - LMP: ___ - Cycles occur monthly, lasting a few days, cramping the first day otherwise manageable, no menorrhagia or dysmenorrhea - History of infertility, s/p IVF work-up, was told at that time that she had unexplained secondary infertility and a cyst (unclear size) - Denies fibroids, polyps, STIs, endometriosis PMH: Morbid obesity, anxiety/depression, eating disorder PSH: D&C, cosmetic breast surgery <SOCIAL HISTORY> ___ <FAMILY HISTORY> Brother requiring heart transplant <PHYSICAL EXAM> 24 HR Data (last updated ___ @ 2321) Temp: 99.0 (Tm 99.4), BP: 110/73 (110-123/73-76), HR: 100 (98-100), RR: 18, O2 sat: 95% (95-97), O2 delivery: Ra Gen: A&O, comfortable, no acute distress, however appears fatigued, chilled PULM: nonlabored breathing Abd: soft, ND, obese, palpable R pelvic mass to 5cm below her umbilicus, tender to palpation, no rebound or guarding MSK: No CVAT bilaterally Pelvic: SSE - normal appearing cervix, small amt of discharge, non foul smelling, no blood or lesions BME - no CMT, nontender uterus and L adnexa, R adnexa full with palpable minimally mobile mass approximately 12cm in size, TTP Ext: ___, symmetric bilaterally, nonerythematous Exam Day of Discharge 24 HR Data (last updated ___ @ 331) Temp: 98.9 (Tm 99.4), BP: 123/75 (110-125/71-79), HR: 102 (87-104), RR: 18, O2 sat: 97% (93-99), O2 delivery: Ra I/Os: Fluid Balance (last updated ___ @ 238) Last 8 hours Total cumulative 0ml IN: Total 800ml, PO Amt 800ml OUT: Total 800ml, Urine Amt 800ml Last 24 hours Total cumulative -414ml IN: Total 2136ml, PO Amt 1800ml, IV Amt Infused 336ml OUT: Total 2550ml, Urine Amt 2550ml General: NAD, sitting up in bed CV: RRR Lungs: nonlabored breathing Abdomen: obese, soft, ND, mildly tender to palpation in RLQ, no rebound or guarding Extremities: no edema, no TTP, nonerythematous <PERTINENT RESULTS> ___ 03: 20PM BLOOD CA125: 487* CA ___: 100* AFP: 1.0 CEA: 1.6 HCG: <5 Na: 142 K: 3.8 Cl: 96 Creat: 0.6 Glucose: 81 ___ 03: 20PM BLOOD WBC: 14.5* ___ 06: 45AM BLOOD WBC: 13.9* ___ 03: 20PM BLOOD Hgb: 10.5* Hct: 34.6 ___ 06: 45AM BLOOD Hgb: 9.5* Hct: 31.3* ___ 03: 20PM BLOOD Plt Ct: 520* ___ 06: 45AM BLOOD Plt Ct: 512* <DISCHARGE INSTRUCTIONS> Dear Ms. ___, You were admitted to the gynecologic oncology service due to lower abdominal pain in the setting of your known pelvic mass. You have recovered well, and the team feels that you are safe to be discharged home with plan for surgery in the near future. Please follow these instructions: 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 * nausea/vomiting where you are unable to keep down fluids/food or your medication * chest pain or difficulty breathing * onset of any concerning symptoms
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Ms. ___ was admitted to the gynecologic oncology service for abdominal pain in setting of large pelvic mass and elevated ___ and CA125. Her pain was controlled with oxycodone and Tylenol. By hospital day 1, she was tolerating a regular diet, voiding spontaneously, ambulating independently, and pain was controlled with oral medications. She continued to have some mild abd pain and desired to stay an additional night. On hospital day 2 she was discharged home in stable condition with upcoming surgery to be scheduled as soon as possible. Discharge Medications: 1. Acetaminophen 1000 mg PO Q6H:PRN Pain - Mild/Fever RX *acetaminophen 500 mg ___ tablet(s) by mouth every six (6) hours Disp #*60 Tablet Refills:*0 2. DiphenhydrAMINE 25 mg PO Q6H:PRN insomnia RX *diphenhydramine HCl 25 mg 1 capsule(s) by mouth at night Disp #*20 Tablet Refills:*0 3. Ondansetron ___ mg PO ONCE MR1 Duration: 1 Dose RX *ondansetron 4 mg 1 tablet(s) by mouth every four (4) hours Disp #*30 Tablet Refills:*0 4. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain - Severe RX *oxycodone 5 mg 1 tablet(s) by mouth every four (4) hours Disp #*10 Tablet Refills:*0 Discharge Disposition: Home Discharge Diagnosis: Pelvic mass Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___
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10996933-DS-17
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Sulfa (Sulfonamide Antibiotics) <ATTENDING> ___. <CHIEF COMPLAINT> Menorrhagia Likely adenomyosis <MAJOR SURGICAL OR INVASIVE PROCEDURE> Total laparoscopic hysterectomy Cystoscopy <HISTORY OF PRESENT ILLNESS> ___ yo P0 (2 adopted children) F with SLE with menorrhagia s/p Novasure endometrial ablation on ___ for long history of menometrorrhagia. Endometrial sampling pre-ablation was negative in ___. After endometrial ablation, she continued to have persistent and occasionally quite heavy vaginal bleeding, at times, quite heavy. Her bleeding has not abated since ___. The flow varies from light bleeding to heavy bleeding w/ passage of large clots. Her Hct in ___ was noted to be 33. She denies any SOB, LH, dizziness. She has mild cramping but denies severe dysmenorrhea or pelvic pain. She is extremely bothered by the chronicity of the bleeding. She states that she has not attempted medical mgt in the past with hormonal methods as per Dr. ___ recommendations. Recent pelvic u/s imaging from ___ showed an enlarged uterus, RV, measuring 9.6 x 7.2 cm w/ marked heterogeneous thickened myometrium w/ scattered tiny cysts consistent w/ adenomyosis. No definite fibroids noted. Endometrium is indistinct. Simple R ovarian cyst measuring 3.2 x 2.2 cm, most likely functional. Normal L ovary. She presented to Dr. ___ to discuss options for further management. The patient elected surgical management given the impact of her menometrorrahagia on her quality of life, and inability to use hormonal management given her underlying SLE. After discussion of the risks and benefits, the patient elected total laparoscopic hysterectomy for management of her symptoms. <PAST MEDICAL HISTORY> PGYNH: Menarche age ___ LMP: ___ Menses irregular, see HPI No h/o abnormal Pap tests Last Pap: ___ Sexually active: Yes Sexual preference: opposite Current contraception: none Prior contraceptive methods used: none Lifetime sexual partners: 5 . H/o infertility H/o HSV - last outbreak ___ yrs ago . POBH: TAB x 3 SAB x 2 . PMH: 1) SLE . PSH: 1) Novasure endomtrial ablation ___ <SOCIAL HISTORY> ___ <FAMILY HISTORY> No breast or gynecologic malignancy <PHYSICAL EXAM> Post operative physical exam: T 96 (axillary) BP110/60 HR 80 RR 12 O2 Sat 100% 2L Gen: NAD, talking, alert Lungs: CTAB CV: S1, S2. III/VI mid-systolic murmur lower left sternal border. Regular rate, rhythm. Abdomen: Bowel sounds present. Nondistended. Mildly tender around port sites, no rebound/guarding. Incisions are intact some small blood on umbilicus dressing. Suture for 2 port sites, dermabond for small 2 port sites (left lateral/right lateral). GU: No staining of vaginal pad. Foley in place. Blue from dye mixed with clear yellow urine. Ext: No edema, tenderness. Pneumoboots in place. <PERTINENT RESULTS> ___ Bedside 12-lead EKG: Normal sinus rhythm. HR 81, intervals wnl, axis normal, no ST/T changes. Comparison: ___ <MEDICATIONS ON ADMISSION> BUPROPION HCL [WELLBUTRIN SR] - 200 mg Tablet Sustained Release - 1 Tablet(s) by mouth once a day HYDROXYCHLOROQUINE [PLAQUENIL] - 200 mg Tablet - two Tablet(s) by mouth once a day IBUPROFEN - 800 mg Tablet - 1 Tablet(s) by mouth three times a day with food PREDNISONE - 5 mg Tablet - two Tablet(s) by mouth once a day <DISCHARGE MEDICATIONS> 1. ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. Disp: *60 Tablet(s)* Refills: *0* 2. hydrocodone-acetaminophen ___ mg Tablet Sig: ___ Tablets PO Q4H (every 4 hours) as needed for pain: maximum daily Tylenol (acetaminophen) is 4000mg, each Vicodin contains 325mg Tylenol (acetaminophen) . Disp: *45 Tablet(s)* Refills: *0* 3. bupropion HCl 100 mg Tablet Sustained Release Sig: Two (2) Tablet Sustained Release PO QAM (once a day (in the morning)). 4. prednisone 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. hydroxychloroquine 200 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 6. Colace 100 mg Capsule Sig: One (1) Capsule PO three times a day as needed for constipation. Disp: *60 Capsule(s)* Refills: *0* <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> menorrhagia adenomyosis <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Call your doctor for: * fever > 100.4 * severe abdominal pain * difficulty urinating * vaginal bleeding requiring >1 pad/hr * abnormal vaginal discharge * redness or drainage from incision * nausea/vomiting where you are unable to keep down fluids/food or your medication General instructions: * Take your medications as prescribed. * Do not drive while taking narcotics. * No strenuous activity and no heavy lifting of objects >10lbs for 6 weeks. * Nothing in the vagina (no tampons, no douching, no sex) for 3 months * You may eat a regular diet. Incision care: * You may shower and allow soapy water to run over incision; no scrubbing of incision. No bath tubs for 6 weeks. * If you have steri-strips, leave them on. They will fall off on their own or be removed during your followup visit.
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Ms. ___ underwent an uncomplicated total laparoscopic hysterectomy and cystoscopy; see operative report for details. She received a stress dose of steroids intraoperatively and twice again postoperatively for her history of prednisone use. On postoperative day #1, she complained of feeling an 'irregular heart beat' after receiving dilaudid; she denied chest pain or dizziness. An EKG was obtained which showed normal sinus rhythm. Her symptoms were attributed to dilaudid administration. The dilaudid was transitioned to vicodin and she remained asymptomatic. Otherwise her postoperative course was uncomplicated. She was discharged home on postoperative day #1 in good condition: ambulating and urinating without difficulty, tolerating a regular diet, and with adequate pain control using PO medication.
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10997760-DS-20
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> endometrial cancer <MAJOR SURGICAL OR INVASIVE PROCEDURE> s/p robotic assisted total laparoscopic hysterectomy, bilateral salpingoophorectomy, pelvic and para-aortic lymphadenectomy <HISTORY OF PRESENT ILLNESS> Ms. ___ is a ___ year-old para 1 woman seen today in consultation for ___ grade 2 endometrial adenocarcinoma, endometrioid type. She noted approximately 1 week of light spotting and some minimal menstrual cramps. She presented to her PCP complaining of postmenopausal bleeding. She was then evaluated by Dr. ___ and on ___ had an endometrial biopsy done in the office. Pathology showed the above and she was referred to Dr. ___. She reports that she has had intermittent low pelvic aching since the endometrial biopsy and daily scant spotting. She denies unintentional weight changes, chest pain, shortness of breath, nausea, vomiting, abdominal pain, bloating, increased abdominal girth, early satiety, constipation, diarrhea, dysuria, vaginal bleeding or abnormal discharge. <PAST MEDICAL HISTORY> PMH: - Migraines - Lentigines. Seborrheic keratosis. - Denies hypertension, diabetes, asthma, thromboembolic disease PSH: - knee surgeries, ___ - open appendectomy - dilation and curettage, premenopausal POB: G1P1 - SVD ___ PGYN: - LMP approximately ___, normal flow lasting 5 days - Denies other postmenopausal bleeding, except as above - Currently sexually active - Hormonal replacement therapy: ___ year aproximately - History of abnormal Pap smears: 1 abnormal Pap approximately ___ years ago followed by all normal results per pt report - Denies history of pelvic infections or sexually transmitted infections - Denies history of fibroids or cysts <SOCIAL HISTORY> ___ <FAMILY HISTORY> - No known family history of breast, uterine, ovarian, cervical or colon cancer <PHYSICAL EXAM> On day of discharge: Afebrile, vitals stable No acute distress CV: regular rate and rhythm Pulm: clear to auscultation bilaterally Abd: soft, appropriately tender, nondistended, incisions clean/dry/intact, no rebound/guarding ___: nontender, nonedematous <PERTINENT RESULTS> ___ 06: 20PM GLUCOSE-137* UREA N-19 CREAT-0.9 SODIUM-139 POTASSIUM-4.4 CHLORIDE-104 TOTAL CO2-26 ANION GAP-13 ___ 06: 20PM estGFR-Using this ___ 06: 20PM CALCIUM-9.5 PHOSPHATE-2.9 MAGNESIUM-1.9 ___ 06: 20PM WBC-13.7*# RBC-4.47 HGB-14.3 HCT-40.9 MCV-92 MCH-32.0 MCHC-35.0 RDW-12.7 RDWSD-42.5 ___ 06: 20PM PLT COUNT-333 <MEDICATIONS ON ADMISSION> Lorazepam Propranolol Sumatriptan Verapamil Vit D <DISCHARGE MEDICATIONS> 1. Acetaminophen ___ mg PO Q6H: PRN pain RX *acetaminophen 500 mg ___ tablet(s) by mouth every six (6) hours Disp #*40 Tablet Refills: *0 2. Docusate Sodium 100 mg PO BID RX *docusate sodium 100 mg 1 tablet(s) by mouth twice a day Disp #*30 Tablet Refills: *0 3. Ibuprofen 400 mg PO Q6H: PRN pain RX *ibuprofen 400 mg 1 tablet(s) by mouth every six (6) hours Disp #*40 Tablet Refills: *0 4. Lorazepam 0.5 mg PO Q4H: PRN anxiety 5. OxycoDONE (Immediate Release) 10 mg PO Q4H: PRN severe pain RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours Disp #*40 Tablet Refills: *0 6. Propranolol 80 mg PO DAILY 7. Sumatriptan Succinate 6 mg SC ONCE: PRN migraine 8. Verapamil 40 mg PO QHS <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> Endometrial cancer, final pathology pending <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Dear Ms. ___, . You were admitted to the gynecologic oncology service after undergoing the procedures listed below. You have recovered well after your operation, and the team feels that you are safe to be discharged home. Please follow these instructions: . * Take your medications as prescribed. * Do not drive while taking narcotics. * Do not combine narcotic and sedative medications or alcohol. * Do not take more than 4000mg acetaminophen (APAP) in 24 hrs. * No strenuous activity until your post-op appointment. * Nothing in the vagina (no tampons, no douching, no sex) for ___ weeks. * No heavy lifting of objects >10 lbs for 4 weeks. * You may eat a regular diet. * It is safe to walk up stairs. . Incision care: * You may shower and allow soapy water to run over incision; no scrubbing of incision. No bath tubs for 6 weeks. * 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 robotic assisted laparoscopic hysterectomy and bilateral salpingoophorectomy, pelvic and paraaortic lymph node dissection. Please see the operative report for full details. Her post-operative course is detailed as follows. Immediately postoperatively, her pain was controlled with IV dilaudid and toradol. Her diet was advanced without difficulty and she was transitioned to PO oxycodone, tylenol, and ibuprofen. On post-operative day #1, her urine output was adequate so her Foley catheter was removed and she voided spontaneously. By post-operative day 1, she was tolerating a regular diet, voiding spontaneously, ambulating independently, and pain was controlled with oral medications. She was then discharged home in stable condition with outpatient follow-up scheduled.
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10997760-DS-21
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> vaginal recurrence of stage 1B grade 2 endometrioid adenocarcinoma of the uterus <MAJOR SURGICAL OR INVASIVE PROCEDURE> interstitial placement, brachytherapy <HISTORY OF PRESENT ILLNESS> Ms. ___ is a ___ female with a FIGO IB grade 2 endometrioid adenocarcinoma of the uterus with LVI, status post uncomplicated TLH-BSO and pelvic and paraaortic lymphadenectomy on ___, followed by vaginal cuff brachytherapy ending ___, now with a biopsy-proven distal vaginal recurrence. <PAST MEDICAL HISTORY> PMH: - Migraines - basal cell carcinoma of LUE - Lentigines. Seborrheic keratosis. - Denies hypertension, diabetes, asthma, thromboembolic disease PSH: - knee surgeries, ___ - open appendectomy - dilation and curettage, premenopausal - b/l carpal tunnel release - TLH, BSO, pelvic and paraaortic lymphadenectomy ___ POB: G1P1 - SVD ___ PGYN: - Post-menopausal - Currently sexually active - Hormonal replacement therapy: ___ year aproximately - History of abnormal Pap smears: 1 abnormal Pap approximately ___ years ago followed by all normal results per pt report <SOCIAL HISTORY> ___ <FAMILY HISTORY> - No known family history of breast, uterine, ovarian, cervical or colon cancer <PHYSICAL EXAM> On day of discharge: Afebrile, vitals stable No acute distress CV: regular rate and rhythm Pulm: clear to auscultation bilaterally Abd: soft, appropriately tender, nondistended, no rebound/guarding GU: interstitial needle sites clean/dry/intact, scant blood on pad ___: nontender, nonedematous <PERTINENT RESULTS> Post-Op Day 1 Labs ___ 07: 02AM BLOOD WBC-5.0 RBC-3.20* Hgb-10.1* Hct-29.5* MCV-92 MCH-31.6 MCHC-34.2 RDW-14.9 RDWSD-49.7* Plt ___ ___ 07: 02AM BLOOD Glucose-139* UreaN-8 Creat-0.7 Na-137 K-3.8 Cl-103 HCO3-24 AnGap-10 ___ 07: 02AM BLOOD Calcium-7.5* Phos-2.2* Mg-1.5* Other Labs ___ 06: 58AM BLOOD WBC-3.3* RBC-3.22* Hgb-10.1* Hct-29.2* MCV-91 MCH-31.4 MCHC-34.6 RDW-15.0 RDWSD-49.8* Plt ___ ___ 06: 58AM BLOOD Neuts-59.8 ___ Monos-11.4 Eos-5.4 Baso-0.6 Im ___ AbsNeut-2.00 AbsLymp-0.75* AbsMono-0.38 AbsEos-0.18 AbsBaso-0.02 <MEDICATIONS ON ADMISSION> 1. Propranolol 80 mg PO/NG DAILY 2. Sumatriptan Succinate 100 mg PO BID: PRN headache 3. Sumatriptan Succinate 100 mg oral BID: PRN migraine 4. Lorazepam 0.5 mg q6h PRN 5. Alendronate 70 mg weekly 6. Vitamin D <DISCHARGE MEDICATIONS> 1. Acetaminophen 1000 mg PO Q6H: PRN Pain - Mild RX *acetaminophen 500 mg ___ tablet(s) by mouth every 6 hours Disp #*60 Tablet Refills: *1 2. Ibuprofen 600 mg PO Q6H pain RX *ibuprofen 600 mg 1 tablet(s) by mouth every 6 hours Disp #*60 Tablet Refills: *1 3. OxycoDONE Liquid ___ mg PO Q4H: PRN Pain - Moderate RX *oxycodone 5 mg ___ tablets by mouth every 4 hours Disp #*20 Tablet Refills: *0 4. Propranolol 80 mg PO/NG DAILY 5. Sumatriptan Succinate 100 mg PO BID: PRN headache 6. Sumatriptan Succinate 100 mg oral BID: PRN migraine 7. Lorazepam 0.5 mg q6h PRN 8. Alendronate 70 mg weekly 9. Vitamin D <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> vaginal recurrence of stage 1B grade 2 endometrioid adenocarcinoma of the uterus <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Dear Ms. ___, . You were admitted to the gynecologic oncology service while undergoing interstitial brachytherapy. You have recovered well, and the team feels that you are safe to be discharged home. Please follow these instructions: * Take your medications as prescribed. 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. . To reach medical records to get the records from this hospitalization sent to your doctor at home, call ___. Best wishes, Your ___ GYN/Oncology Team
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Ms. ___ 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 6 sessions. She was maintained on bedrest, a clear diet, and loperamide throughout this time. Her pain was controlled with a dilaudid and then morphine PCA, epidural anesthesia, and acetaminophen. . After removal of the implant on hospital day 4, her diet was advanced without difficulty. She was transitioned to oral acetaminophen for her pain. On hospital day 5, her Foley catheter was removed and she voided spontaneously. She was seen by Physical Thearpy, who assessed her as having no further needs. . By hospital day 5, she was tolerating a regular diet, voiding spontaneously, ambulating independently, and pain was controlled with oral medications. She was then discharged home in stable condition with outpatient follow-up scheduled.
| 1,460
| 214
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11000705-DS-13
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Penicillins / Aspirin <ATTENDING> ___. <CHIEF COMPLAINT> spotting <MAJOR SURGICAL OR INVASIVE PROCEDURE> none <HISTORY OF PRESENT ILLNESS> ___ y/o G2P1 with IVF di/di twins at 26+1 weeks presents after noting approximately quarter size spot on her pad last evening. Pt denies any further episodes of bleeding. Reports active fetal movement. No leaking of fluid. Patient denies any abdominal pain. Pt has intermittent contractions but she reports that she has always had these and there is no increased frequency or intesity. <PAST MEDICAL HISTORY> PRENATAL COURSE ___ ___ *)A-/Ab+ in ___ NR/HepBsAg neg *)di/di twins: - U/S: (___) A 410g, B 489g (___) A 757g, B 1041g OBSTETRIC HISTORY ___ LTCS, ___, due to surgical hx GYNECOLOGIC HISTORY denies PAST MEDICAL HISTORY - Ulcerative colitis: s/p colectomy and multiple distal structures PAST SURGICAL HISTORY - colectomy - C/S <SOCIAL HISTORY> ___ <FAMILY HISTORY> non-contributory <PHYSICAL EXAM> (on admission) VITALS: T 97, HR 98, RR 18, BP 115/71 GENERAL: NAD ABDOMEN: soft gravid NT EXTREMITIES: no calf tenderness SSE: Os closed, no bleeding or discharge noted FHT: A: 150s/mod var/+A/no D B: 150s/mod var/+A/no D TOCO: Irregular, Q5 to 10 -> then increased to Q3min SVE: L/C/P TAUS: A: BPP ___, FHR 150, VTX B: BPP ___, FHR 158, Transverse <PERTINENT RESULTS> ___ WBC-11.2 RBC-3.98 Hgb-12.9 Hct-37.9 MCV-95 Plt-323 ___ WBC-12.5 RBC-3.58 Hgb-11.7 Hct-33.5 MCV-94 Plt-313 ___ ___ PTT-23.5 ___ ___ ___ PTT-24.5 ___ ___ BLOOD FetlHgb-0 ___ URINE Blood-NEG Nitrite-NEG Protein-TR Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-LG <MEDICATIONS ON ADMISSION> Anusol suppository, 25mg QD Flagyl 250 BID Folic acid <DISCHARGE MEDICATIONS> Anusol suppository, 25mg QD Flagyl 250 BID Folic acid <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> Twins Preterm contractions vaginal bleeding <DISCHARGE CONDITION> good <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> limited heavy lifting no more than 25 pounds no exercise modified bedrest
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___ y/o G2P1 with IVF di/di twins admitted at 26+1 weeks with vaginal bleeding. . Ms ___ was hemodynamically stable and without any further bleeding on arrival to labor and delivery. Sterile speculum exam was negative for blood and her cervix was closed and long by digital exam. She was contracting irregularly on toco and fetal testing was reassuring. She was given a course of betamethasone for fetal lung maturity and the NICU was consulted. She underwent prolonged monitoring on labor and delivery and she remained stable. Her contractions spaced out and she had no further vaginal bleeding. CBC and coags were stable. She received Rhogam due to her RH negative status. ___ was negative. She was transferred to the antepartum floor for further observation from ___ adn ___ and after more than 72 hours had no more episodes of bleeding. In the end, it was unclear if htis was due to proctitis or true vaginal bleeding as no blood was ever seen in the vaginal/cervix area. She was betamethasone complete on ___. On ___, ulrasound revealed a cervical length of 4.7cm. Her twins were vertex/breech, BPPs ___ x 2. She was dicharged home at 26+4 weeks and she will have close outpatient followup.
| 684
| 282
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11000705-DS-14
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Penicillins / Aspirin <ATTENDING> ___. <CHIEF COMPLAINT> Scheduled Cesarean Section <MAJOR SURGICAL OR INVASIVE PROCEDURE> Cesarean Section <HISTORY OF PRESENT ILLNESS> ___ is a ___ gravida 2, para 1 whose due date was ___ at 37+ 5 weeks with di/di twins. She has a history of ulcerative colitis s/p total colectomy with ileo-anal pouch creation as well as a prior cesarean section via midline incision. She was admitted for elective repeat cesarean section. Prior arrangements had been made to allow Dr. ___ general surgery to be present. Prenatal course: ___: ___ A-/ab neg/ RPR NR/RbI/HbSag neg rhogham given once this pregnancy ___ A 2600g, 37% B 2700g, 45% <PAST MEDICAL HISTORY> PAST OBSTETRICAL HISTORY: ___ ___, Primary CS by vertical incision skin, 4000g and due to GI disease PAST GYN HISTORY: Significant for unknown infertility. She had a polyp in her last pregnancy that was removed by Dr. ___. She has had a last Pap smear in ___ in ___. PAST MEDICAL HISTORY: Significant for ulcerative colitis diagnosed in ___. She was treated after having many failed medical regimens with a total colectomy and an appendectomy. She is then gone on to have multiple problems with strictures and has multiple bowel movements a day. She is followed very closely by Dr. ___. She has also had a bleeding workup because she has spontaneous bleed from her pouch and that bleeding workup was completely negative. PAST SURGICAL HISTORY: Again, a colectomy and appendectomy. She has also had strictures status post multiple dilations in ___, and ___. Cesarean delivery in ___, vertical skin incision <SOCIAL HISTORY> ___ <FAMILY HISTORY> non-contributory <PHYSICAL EXAM> On discharge: VS T 98.4 BP 120/70 HR 64 RR 18; 24 hour urine output 3250, stool output 1250, input ~2500 in IV and regular diet NAD RRR CTAB +normoactive BC, NT, nondistended, no rebound or guarding, fundus firm below umbilicus. Midline vertical incision with staples, clean, dry, no ooze. lochia minimal. ___ <PERTINENT RESULTS> Labs: ___ Hct Plt Ct ___ 01: 00PM 5.2 40.5 273 ___ 10: 30AM 8.1 44.6 252 ___ 7.5 37.9 283 Gl BUN Cr Na K Cl HCO3 ___ 08: 00AM ___ 142 3.8 109* 22 ___ 06: 10AM 104 4* 0.5 141 3.8 109* 23 ___ 06: 50AM 100 4* 0.5 139 3.7 109* 23 ___ 09: 04AM 79 5* 0.5 138 3.9 105 21* ___ 06: 20AM ___ 137 3.8 ___ 01: 00PM ___ 134 3.9 ___ 10: 30AM ___ 134 3.5 101 21* Ca Phos Mg ___ 08: 00AM 8.8 4.3 1.9 ___ 06: 10AM 8.8 3.7 1.9 ___ 06: 50AM 8.4 4.0 1.9 ___ 09: 04AM 8.2* 3.7 1.9 ___ 06: 20AM 8.0* 3.1 1.9 ___ 01: 00PM 8.0* 3.1# 2.1 ___ 10: 30AM 8.7 5.1*# 1.6 ALT AST LDH AlkPhos Amylase TBili ___ 08: 00AM 301* ___ 06: 10AM 317* ___ 06: 50AM 269* ___ 09: 04AM 360* ___ 06: 20AM 221 ___ 05: 40PM ___ 123* 42 0.3 ___ 10: 30AM ___ 151* 47 0.3 UA ___: Mod blood, 100 Protein, pH 7.5, Mod leuks Micro ___: 57 RBCs, 298 WBCs, no bacteria, no yeast, no epithelial cells Urine culture final ___: E. coli, pan-sensitive Imaging: KUB ___: 1. Dilated loops of small bowel, concerning for small-bowel obstruction. 2. Expected post-surgical free air. CT ___: IMPRESSION: 1. Diffuse dilation of small bowel from the ligament of Treitz to the anus, which is narrowed and hyperenhances, likely from stenosis and scar tissue from prior instrumentation (dilation). 2. Incompletely characterized right hepatic lobe lesions. Further characterization with MRI with Eiovist or BOPTA is recommended. 3. Intraperitoneal free air and fluid, likely postoperative in etiology. Gas in the endometrium likely due to Caesarean section one day prior. 4. Duplicated left collecting system. The ureters appear to merge in the lower retroperitoneum. KUB ___: Dilated loops of small bowel unchanged from prior study. Intra-abdominal free air is likely secondary to recent operation. KUB ___: No change in dilated loops of small bowel most likely representing ileus. KUB ___: Slight interval increase in dilated loops of small bowel. Interval removal of NG and rectal tubes. <MEDICATIONS ON ADMISSION> FOLIC ACID - 1 mg Tablet - 1 Tablet(s) by mouth once a day HYDROCORTISONE ACETATE [ANUSOL-HC] - 25 mg Suppository - 1 suppository rectally once a day METRONIDAZOLE - 250 mg Tablet - 1 (One) Tablet(s) by mouth twice a day PANTOPRAZOLE - 20 mg Tablet, Delayed Release (E.C.) - 1 Tablet(s) by mouth bid ___ hour before break fast and dinner IRON - (OTC) - Dosage uncertain MULTIVITAMIN - (OTC) - Tablet - 1 Tablet(s) by mouth once a day <DISCHARGE MEDICATIONS> 1. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO twice a day for 7 days. Disp: *14 Tablet(s)* Refills: *0* 2. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp: *30 Tablet(s)* Refills: *0* <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> CS Partial small bowel obstruction Ulcerative colitis with possibel pouchitis <DISCHARGE CONDITION> good <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> given
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Mrs. ___ was admitted and had an uncomplicated repeat cesarean section on ___. Full operative report available in OMR. She did well in the recovery room and was taken to the floor in good condition. On the postpartum floor, she had some pain issues on POD #0. She was given extra doses of pain medication with decent relief. Notably, she had gotten a perioperative TAP block. On POD #1, she developed nausea and vomiting with tachycardia and abdominal distention. She was made NPO with IVF and a Dilaudid PCA for pain. GI and general surgery were consulted. Notes available in OMR. A NGT was placed with efflux of 550 cc of bilious fluid immediately. A rectal tube was placed by GI later that evening and drained 500 cc of stool over several hours. A KUB was performed that was suspicious for SBO, and a CT was done which showed narrowing at the anal pouch anastomosis site, an area of known stricture. The GI and surgery teams felt the diagnosis was likely a partial SBO vs an issue with her pouch. Over the next two days, the patient was continued NPO with IV fluids. Daily labs were collected and lytes were repleted as necessary. Daily KUBs were performed at the recommendation of GI; these demonstrated ileus. Her exam continued to show distention and hypoactive bowel sounds. On POD #3, the NGT was removed. Rectal tubes were periodically placed and removed by GI (to allow the patient to ambulate), and were productive of large amounts of stool each time. The Foley catheter was removed, but Mrs. ___ noted discomfort with voiding on POD #3. A UA was sent which showed significant WBCs but no bacteria. Despite no culture results at this time, the decision was made to empirically treat with Cipro. She was started on IV Cipro as she was still not taking POs. The patient finally began to pass increased flatus and stool on her own and her diet was advanced to clears on POD #5. By POD #6, the patient was tolerating a regular, bland, low-residue diet without nausea or vomiting and passing adequate stool. She was transitioned to PO medications and was felt ready for discharge home on POD #7. She was discharged home in good condition.
| 1,604
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11003999-DS-5
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Prevpac / Oxycodone / Dilaudid / Penicillins / Shellfish Derived <ATTENDING> ___ <CHIEF COMPLAINT> pelvic pain <MAJOR SURGICAL OR INVASIVE PROCEDURE> total abdominal hysterectomy, bilateral endometrioma drainage <HISTORY OF PRESENT ILLNESS> Pt is a ___ gravida 0 with a known history of pelvic abdominal pain. On her last ultrasound of ___, the patient had an enlarged uterus, which measured 10.6 x 6.0 x 7.9 cm, again demonstrated the inferiorly in the myometrium is a focal mass which measures 6.8 x 4.2 x 5.3 cm, which has been demonstrated to represent adenomyosis on comparison MR. ___ entity is unchanged in size when compared to the last ultrasound. Endometrium was distorted and measures 9 mm fundus. Posterior to the uterus and extending into the adnexa, complex cystic structure which measures 9.5 cm in transverse dimension. This is most consistent with endometrioma with an associated left hematosalpinx. The pt underwent an exploratory laparotomy, total abdominal hysterectomy, lysis of adhesions, drainage of bilateral endometriomas, bilateral ovarian biopsies, and cystoscopy for her history of pelvic pain, endometriosis, fibroids, and irregular bleeding. She was admitted to the gynecology service following her operation. <PAST MEDICAL HISTORY> Chronic abdominal pain, uterine fibroids, endometriosis, peptic ulcer disease, panic attacks, TMJ, migraine headaches, hyperlipidemia <SOCIAL HISTORY> ___ <FAMILY HISTORY> NC <PHYSICAL EXAM> On post-operative check on floor: VS 98.2 159/96 71 18 100% on 2L NC Mild distress recovering post-op CTAB RRR nl S1 S2 Abd soft, ND, +BS, appropriately tender, no rebound, mild guarding. low-transverse incision without erythema or induraction, dressing without bleeding. Pelvic: foley in place, no blood noted in bag Ext: compression boots in place, +DP pulses, sl edema <PERTINENT RESULTS> ___ 06: 50AM BLOOD WBC-7.3 RBC-3.26* Hgb-8.5* Hct-26.1* MCV-80* MCH-26.1* MCHC-32.5 RDW-19.4* Plt ___ ___ Chest Xray: Frontal and lateral views of the chest demonstrate intraperitoneal air best seen under the right hemidiaphragm. There is focal atelectasis versus airspace opacity in the lingula. Remainder of the lungs are clear. Heart and mediastinum are within normal limits. ___ Urine culture no growth <MEDICATIONS ON ADMISSION> atenolol 25mg', protonix ER 40mg', sucralfate <DISCHARGE MEDICATIONS> 1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation. Disp: *60 Capsule(s)* Refills: *2* 2. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). 3. acetaminophen-codeine 300-30 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. Disp: *45 Tablet(s)* Refills: *0* 4. Iron (ferrous sulfate) 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO once a day. Disp: *30 Tablet(s)* Refills: *2* <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> pelvic pain, endometriosis, fibroid uterus, irregular bleeding <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 Gynecology service after your surgery. General instructions: * Take your medications as prescribed. * Do not drive while taking narcotics. * No strenuous activity, nothing in the vagina (no tampons, no douching, no sex), no heavy lifting of objects >10lbs for 3 months * You may eat a regular diet. Incision care: * You may shower and allow soapy water to run over incision; no scrubbing of incision. No bath tubs for 6 weeks. * If you have steri-strips, leave them on. They will fall off on their own or be removed during your followup visit. * If you have staples, they will be removed at your follow-up visit. To reach medical records to get the records from this hospitalization sent to your doctor at home, call ___.
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Ms. ___ underwent an uncomplicated total abdominal hysterectomy and drainage of bilateral endometriomas; see operative report for details. Her recovery was complicated by fever on postoperative day 2. Her fever resolved, there were no focal signs of infection and no source was identified. She was discharged home on postoperative day #5 in good condition: ambulating and urinating without difficulty, tolerating a regular diet, and with adequate pain control using PO medication.
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11005172-DS-8
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Patient recorded as having No Known Allergies to Drugs <ATTENDING> ___ <CHIEF COMPLAINT> Stage IIIb squamous cell carcinoma of the cervix. <MAJOR SURGICAL OR INVASIVE PROCEDURE> Interstitial catheter implantation. <HISTORY OF PRESENT ILLNESS> ___ woman sent to this clinic in consultation for recently discovered cervical cancer. Ms. ___ and Dr. ___ have requested this consultation for this patient who was noted to have an abnormal Pap smear evidently and a biopsy of a cervical mass was obtained revealing squamous cell carcinoma. The patient reports having no symptoms at this time. After her exam in ___, she had a little bit of bleeding but overall has had no symptoms at all. She has had no vaginal discharge. She denies any difficulty with urination. She denies any bright red blood per rectum. She denies any lower extremity swelling or pain and has no symptoms of sciatic pain on either lower extremity. She reports otherwise feeling in fairly good health. <PAST MEDICAL HISTORY> PAST MEDICAL HISTORY: Benign. She denies any history of asthma, hypertension, mitral valve prolapse, or thromboembolic disorder. She reports that her last mammogram was obtained in ___, she has not had any since. She reports her last Pap smear was obtained in ___, and she had not had another exam since that time. PAST SURGICAL HISTORY: She has a scar on her neck, which is a result of surgery in ___, her native ___. Evidently, she had surgery for "nerves" which appears to be a partial thyroidectomy, although she has no history of requiring any thyroid medications at this time. OB/GYN HISTORY: She is a gravida 3, para 3 woman reports her last menstrual cycle in the year ___. <SOCIAL HISTORY> ___ <FAMILY HISTORY> Denies any 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. BACK: No spinal or CVA tenderness. CHEST: Lungs clear bilaterally. HEART: Regular rate and rhythm. No appreciable murmurs. ABDOMEN: Soft, nontender, nondistended. There are no palpable masses. There is no inguinal adenopathy. EXTREMITIES: There is no clubbing, cyanosis, or edema. There is no calf tenderness to palpation. PELVIC: Normal external genitalia. Speculum is placed and an endocervical cancer is identified. The cervix appears completely replaced by tumor, especially on the left side where it extends to encase the upper third of the vagina on the left side and down along the left vaginal wall. The mass is pulled and tethered to the left side suggesting a parametrial disease. The uterus on bimanual exam is nonmobile and is tethered on to the left side. The tumor extends approximately 6-7 cm, but is non-fungating. It extends from the right side of the cervix into the parametria on the right side. Rectal exam confirms parametrial mass and nodularity. The cervix and uterus are completely tethered on this side with this 7 cm mass. <MEDICATIONS ON ADMISSION> COMPAZINE LORAZEPAM MULTIVITAMIN RANITIDINE Scopolamine ZOFRAN <DISCHARGE MEDICATIONS> 1. Acetaminophen 325 mg Tablet Sig: ___ Tablets PO every ___ hours as needed. 2. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Continue home medications. <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> stage IIIB cervical cancer <DISCHARGE CONDITION> stable <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Please call your doctor for increased abdomenal pain, fevers, chills, chest pain, shortness of breath, heavy vaginal bleeding, leg pain/swelling, incision redness/drainage, any concerns. No driving while on narcotics. Nothing in the vagina for 6 weeks. No heavy lifting for 6 weeks. No swimming or hot tubs for 6 weeks.
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___ yo was admitted ___ status post interstitial catheter implantation secondary to Stage IIIB cervical cancer. Intraoperative course. The intraoperative course was uncomplicated. Please see the dictated operative report for full details. Postoperative course. Pt was placed on routine brachytherapy protocol. The catheters were removed ___ without difficult. There were no postoperative complications. The pt was discharged home on ___ in stable condition.
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11005766-DS-15
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Sulfa (Sulfonamide Antibiotics) <ATTENDING> ___. <CHIEF COMPLAINT> Breast abscess, cellulitis <MAJOR SURGICAL OR INVASIVE PROCEDURE> drainage of abscess <HISTORY OF PRESENT ILLNESS> Ms ___ is a ___ yo G2P2 3wks s/p VBAC who has been treated for mastitis but presents ___ worsening symptoms. Noted breast erythema/ tenderness beginning approx 1 week ago. Continued to pump/breast feed, use warm compresses. Was started on diclox ___ persistent sx. Shortly after beginning diclox she developed hives. Saw Dr. ___ eval. At that time milk, nasal, and skin cx were sent. She was started on clinda. 48hrs later she noted worsening pain/ erythema/ induration. No fevers, chills. No n/v. Of note, cx results obtained on admission +MRSA. <PAST MEDICAL HISTORY> OBHx: G2P2 - LTCS for arrest - VBAC GynHx: - Denies abnormal Pap, fibroids, Gyn surgery, STIs PMH: IBS PSH: LTCS, tonsillectomy <SOCIAL HISTORY> ___ <FAMILY HISTORY> Non contributory <PHYSICAL EXAM> T 98.2, HR 67, BP 111/67 RR 16 O2 100% NAD R breast with 8x6cm area of redness/ induration in upper/inner quadrant. 3cm area of fluctuance concerning for abscess. L breast wnl abd soft, NT, ND ext NT, NE <PERTINENT RESULTS> ___ 06: 56PM BLOOD WBC-8.0 RBC-4.59 Hgb-14.1 Hct-41.3 MCV-90 MCH-30.7 MCHC-34.2 RDW-12.3 Plt ___ ___ 06: 56PM BLOOD Glucose-81 UreaN-19 Creat-0.7 Na-141 K-4.1 Cl-105 HCO3-25 AnGap-15 <MEDICATIONS ON ADMISSION> PNV, zantac, tums, benadryl prn <DISCHARGE MEDICATIONS> 1. Oxycodone-Acetaminophen (5mg-325mg) ___ TAB PO Q4H: PRN Pain RX *oxycodone-acetaminophen [Percocet] 5 mg-325 mg ___ tablet(s) by mouth every four (4) hours Disp #*20 Tablet Refills: *0 2. Ibuprofen 600 mg PO Q6H: PRN Pain 3. Clindamycin 300 mg PO Q6H breast abscess Duration: 14 Days RX *clindamycin HCl 300 mg 1 capsule(s) by mouth every six (6) hours Disp #*56 Capsule Refills: *0 <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> Mastitis with abscess <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Take antibiotic, continue breastfeeding.
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Ms ___ is a ___ yo P2 3wks PP with breast abscess/ cellulitis. On exam there was a 8x6cm area of redness of right breast. Ultrasound was done and confirmed a 3cm abscess. Patient was found to be MRSA positive. An incision and drainage was done on right breast abscess by surgery team. A specimen of aspirate was sent for culture. The area was dressed with sterile gauze and Tegederm in a manner that allowed maximal exposure of her areola and nipple for continued pumping of milk. Patient was then started on IV vancomycin which was then trasitioned to po clindamycin. Patient was discharged on hospital day 2 in stable condition with a 14 day course of clindamycin with instructions to follow up with primary ob in 2 weeks.
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11005836-DS-10
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Patient recorded as having No Known Allergies to Drugs <ATTENDING> ___. <CHIEF COMPLAINT> Fever <MAJOR SURGICAL OR INVASIVE PROCEDURE> None <HISTORY OF PRESENT ILLNESS> ___ year-old ___ 2 Para 0 at 21 weeks 2 days GA presented to the ED with fever and flank pain. She reported bilateral flank pain, mild nausea and denied any vaginal bleeding, contractions, or leakage of fluid. She was feeling active fetal movement. . Upon arrival to the ED she was found to have fever 101.1, tachycardia to 120 and hypotension with blood pressure 80/50s. Examination revealed CVA tenderness. Labs revealed a white blood count of 18 and urinalysis had >50 WBC. The clinical picture was consistent with pyelonephritis. Ceftriaxone was administered. Given the persistent hypotension despite 4 Liters of IV fluid, the decision was made to admit her to the FICU. . Of note she has hyperthyroidism and had not be taking her PTU for the last 2 weeks. <PAST MEDICAL HISTORY> Prenatal Course: 1. Dating: estimated due date ___ 2. Labs: A+/RI/HepB S Antigen -/RPRNR/HIV negative 3. Ultrasound: normal full fetal survey 4. Issues: Hyperthyroidism . Past Obstetric History: spontaneous abortion x 1 . Past Gynecologic History: -___ Abnormal Pap->Colpo with normal biopsy -h/o GC/chlamydia->negative ___ . Medical History: Hyperthyroidism (___) . Surgical History: Right eye surgery <SOCIAL HISTORY> ___ <FAMILY HISTORY> Maternal Great Uncle had ___ disease, mother has thyroid dysfunction. No other family history of other autoimmune diseases. <PHYSICAL EXAM> On Presentation: V/S Tm: 100.7, Tc: 98.8, BP 90/44 - 109/33, HR 81-122, RR ___, O2 92-96% 2L Gen: Young woman in NAD HEENT: Slight bilateral proptosis with very slight soft tissue swelling in area of epicanthal fold over left eye. OP clear without erythema or exudate. Neck: Thyroid gland small, firm, slightly irregular on left, without tenderness to palpation. Pulm: Good respiratory effort with no audible wheezes, rhonchi, or rales CV: Tachycardic, nl s1/s2 Abd: Gravid, soft, non-tender, +BS Back: No significant CVA tenderness Skin: No acanthosis nigricans, no rashes, left forearm tattoo Ext: Warm and well perfused without lower extremity edema <PERTINENT RESULTS> ___ WBC-18.0*# RBC-3.42* Hgb-10.9* Hct-30.1* MCV-88 Plt ___ ___ Neuts-93.3* Lymphs-4.5* Monos-1.6* Eos-0.5 Baso-0.1 ___ WBC-14.4* RBC-2.92* Hgb-9.2* Hct-25.9* MCV-89 Plt ___ ___ WBC-11.7* RBC-2.57* Hgb-8.2* Hct-22.7* MCV-88 Plt ___ ___ Neuts-85.9* Lymphs-10.1* Monos-3.8 Eos-0.1 Baso-0.1 ___ Hct-28.9*# ___ WBC-10.3 RBC-2.88* Hgb-9.3* Hct-25.4* MCV-88 Plt ___ ___ WBC-6.2 RBC-3.08* Hgb-9.6* Hct-27.3* MCV-89 Plt ___ . ___ ___ PTT-30.2 ___ ___ ___ PTT-36.0* ___ . ___ Glucose-123* UreaN-7 Creat-1.1 Na-136 K-3.1* Cl-102 HCO3-21* ___ Glucose-96 UreaN-7 Creat-0.7 Na-139 K-3.5 Cl-112* HCO3-15* ___ Glucose-97 UreaN-6 Creat-0.7 Na-130* K-3.8 Cl-100 HCO3-17* ___ Glucose-89 UreaN-6 Creat-0.8 Na-140 K-3.4 Cl-110* HCO3-19* ___ Glucose-76 UreaN-5* Creat-0.8 Na-136 K-4.1 Cl-108 HCO3-19* . ___ ALT-14 AST-21 AlkPhos-57 TotBili-0.6 ___ ALT-13 AST-25 LD(LDH)-200 AlkPhos-47 TotBili-0.4 . ___ Albumin-3.0* Calcium-6.7* Phos-1.6* Mg-1.4* ___ Calcium-6.4* Phos-2.1* Mg-2.2 Iron-10* ___ Mg-1.7 ___ Albumin-2.9* Calcium-8.3* Mg-1.9 . ___ calTIBC-179* Ferritn-129 TRF-138* . ___ 11: 49AM BLOOD TSH-0.19* ___ 11: 49AM BLOOD T3-146 Free T4-0.86* ___ 09: 17PM BLOOD T4-9.4 calcTBG-1.28 TUptake-0.78 T4Index-7.3 ___ 04: 54AM BLOOD PTH-16 ___ 07: 45AM BLOOD TSH-1.0 ___ 07: 45AM BLOOD T3-129 Free T4-0.96 . ___ ___ Temp-39.1 pH-7.34* Comment-GREEN TOP ___ ___ pH-7.43 . ___ URINE Blood-NEG Nitrite-POS Protein-30 Glucose-100 Ketone-TR Bilirub-NEG Urobiln-1 pH-5.0 Leuks-MOD ___ URINE ___ WBC->50 Bacteri-MANY Yeast-NONE ___ URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG . URINE CULTURE (Final ___: ESCHERICHIA COLI. >100,000 ORGANISMS/ML.. SENSITIVITIES: MIC expressed in MCG/ML AMPICILLIN------------ <=2 S AMPICILLIN/SULBACTAM-- <=2 S CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CEFUROXIME------------ 2 S CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- <=16 S PIPERACILLIN---------- <=4 S PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S . URINE CULTURE (Final ___: <10,000 organisms/ml. . Blood cultures ___: no growth . Echocardiogram ___: IMPRESSION: Normal LV cavity size with normal global and regional biventricular systolic function. No diastolic dysfunction or significant valvular disease seen. Small pericardial effusion located posterior to inferolateral wall without evidence of tamponade. . Chest X-Ray ___: Final Report INDICATION: ___ female who is pregnant with pyelonephritis and shortness of breath after fluid. PA AND LATERAL CHEST RADIOGRAPHS: There is bilateral predominantly lower lobe air space opacity with air bronchograms. There is prominent azygos vein. The heart size is normal. There are no pleural effusions on this frontal radiograph. Findings are consistent with pulmonary edema. . Bilateral Lower Extremity Venous Doppler ___: CLINICAL HISTORY: Acute onset of shortness of breath, 21 weeks pregnant. Evaluate for deep vein thrombosis. Normal flow and compressibility was present in the common femoral, superficial femoral, and popliteal veins in both the right and left side. No evidence of thrombus in either calf was seen. IMPRESSION: No evidence of deep vein thrombosis. . Renal Ultrasound ___: INDICATION: 21 weeks pregnant with pyelonephritis. Please assess for hydronephrosis or perinephric abscesses. FINDINGS: The right kidney measures 11.7 cm. The left kidney measures 10.6 cm. There is moderate bilateral hydronephrosis. No definite stones are identified in either kidney. Renal parenchymal abnormalities are identified to suggest abscess. An intrauterine pregnancy is present with fetal heart rate of 167 beats per minute. IMPRESSION: Moderate bilateral hydronephrosis and small amount of right perinephric fluid with no sonographic evidence for renal abscesses. As no renal stones are identified and the entire course of the ureters is not visualized, it is not possible to determine whether the hydronephrosis present relates to pregnancy or other causes. <MEDICATIONS ON ADMISSION> PNV Propylthiouracil 100mg BID (has not taken for 2 weeks) <DISCHARGE MEDICATIONS> 1. Nitrofurantoin (Macrocryst25%) 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day): for 10 days, then once daily for rest of pregnancy. Disp: *50 Capsule(s)* Refills: *2* <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> Pyelonephritis <DISCHARGE CONDITION> Good <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Take Antibiotics as prescribed - twice a day for 10 days, then once a day for rest of pregnancy. Call with abdominal pain, pain or burning with urination, vaginal bleeding, or any other problems.
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MICU COURSE: # Acute pyelonephritis: Treated with ampicillin and gentamicin per OB recommendations. Renal ultrasound did not show perinephric abscess. Continued to have intermittent low grade fevers while in the ICU . # Hypotension: Patient met the criteria for sepsis, howevere per prior OMR notes, blood pressures had been running in 90's, so patient not hypotensive per her parameters. . # Tachycardia: Differential diagnosis includes hyperthyroidism though per endocrine consult, felt that based on her labs, she was likely hypothroid. However, may be a sign of early dilated cardiomyopathy. Echocardiogram was normal. Was minimally fluid responsive. Ruled out deep vein thrombosis with lower extremity venous Dopplers. . # Oxygen desaturation: Oxygen saturation in the mid ___ on hospital day #2. Patient was approximately 9 liters positive. Chest x-ray was consistent with pulmonary edema . # Pregnancy at 21 weeks: Fetal heart rate was reassuring on admission. Continued prenatal vitamins. Had daily fetal heart rate spot checks that were reassuring. . # ___ Disease status post eye surgery: TSH is low at 0.19. Free T4 is also low at 0.86. This may be a result of increased thyroid binding globulin induced by hyper-estrogen state. Also, patient had not been taking PTU for 2 weeks. The importance of taking this medication for fetal well-being was explained to the patient and she understood this conversation. Endocrinology consult placed for recommendations regarding thyroid hormone level normalization. . # Hypokalemia: Etiology unclear, was 3.1 on admission. Resolved with repletion. Only 1 episode of diarrhea ~2 weeks ago. Kidney function normal. Oral intake had been good until 3 days ago. . # Anemia: Likely dilutional and secondary to pregnancy, appears to also have iron deficiency component. Recevied 1 unit packed red blood cells for hematocrit of 22. . # Hypocarbia: Likely a hyperchloremic metabolic alkalosis secondary to fluid resuscitation. ___ also be a consequence of tachypnea. . . The patient was called out of the ICU on hospital day #3. Clinically she was stable with no oxygen requirement and stable blood pressure. She continued on IV ampicillin and gentamicin until she was afebrile for 48 hours on the evening of hospital day #5. Her initial urine culture grew pan-sensitive E. Coli and she was transitioned to oral Nitrofuantoin. She remained afebrile and was discharged home on hospital day #6. She will remain on suppression for the remainder of her pregnancy. . While hopsitalized, she was followed by the endocrine service. Her thyroid function tests were normal off medication and they believed her ___ to be in remission and that she should remain off the propylthiouracil that she had been taking. She will follow up with endocrine as an outpatient.
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11005836-DS-11
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> Pyelonephritis Fevers <MAJOR SURGICAL OR INVASIVE PROCEDURE> None <HISTORY OF PRESENT ILLNESS> ___ yo G3P2 5wk s/p SVD and PPTL presents to ED for second day in a row for suprapubic and R flank pain. She was discharged from ED yesterday with diagnosis of UTI and given a course of cipro. She reports Tmax of 102 at home as well as worsening pain. She has decreased appetite but denies N/V. She denies CP, SOB, breast pain, incisional pain, abnormal discharge, or calf pain. She does report incontinence but no dysuria. Prelim UCx from yesterday is growing out E. Coli. In the ED, she has received 1G tylenol, 2L IVF, and 1G ceftriaxone. <PAST MEDICAL HISTORY> OB History: - G3P2 - G1 SAB - G2 SVD, uncomplicated - G3 SVD + PPTL, uncomplicated <PAST MEDICAL HISTORY> - ___ disease, in remission since ___, no medications - asthma - anxiety Past Surgical History : - right eye decompression in ___ with some residual diplopia - PPTL <SOCIAL HISTORY> ___ <FAMILY HISTORY> Maternal Great Uncle had ___ disease, mother has thyroid dysfunction. No other family history of other autoimmune diseases. <PHYSICAL EXAM> On day of admission: PE: Tm 103.1 Tc 99.8 101/58 142->98 18 99% RA Gen: appears tired CV: RRR Pulm: CTAB Breast: no erythema, NT, no evidence of engorgement Abd: soft, suprapubic TTP, no rebound/guarding, incision- well healed, C/D/I Back: R CVAT Pelvic: NEFG, pink vaginal mucosa, normal appearing discharge, cervix appears closed, no CMT, RV NT uterus, TTP of anterior vaginal wall, no adnexal TTP Ext: no calf TTP, no edema On day of discharge: Gen: NAD, well appearing CV: RRR Pulm: CTAB Abd: soft, nontender, nondistnded, mild suprapubic pain to deep palpation, no rebound/guarding, incision- well healed, C/D/I Back: No CVA tenderness Ext: no calf TTP, no edema <PERTINENT RESULTS> ___ 06: 40AM BLOOD WBC-4.3# RBC-3.53* Hgb-10.3* Hct-32.1* MCV-91 MCH-29.2 MCHC-32.1 RDW-13.1 RDWSD-43.9 Plt ___ ___ 03: 26PM BLOOD WBC-9.3 RBC-4.55 Hgb-13.3 Hct-41.5 MCV-91 MCH-29.2 MCHC-32.0 RDW-13.2 RDWSD-44.8 Plt ___ ___ 05: 50PM BLOOD WBC-8.6 RBC-4.53 Hgb-13.3 Hct-41.3 MCV-91 MCH-29.4 MCHC-32.2 RDW-13.2 RDWSD-43.6 Plt ___ ___ 03: 26PM BLOOD Neuts-80.6* Lymphs-13.1* Monos-5.8 Eos-0.0* Baso-0.2 Im ___ AbsNeut-7.47* AbsLymp-1.21 AbsMono-0.54 AbsEos-0.00* AbsBaso-0.02 ___ 05: 50PM BLOOD Neuts-81.9* Lymphs-11.0* Monos-6.5 Eos-0.2* Baso-0.1 Im ___ AbsNeut-7.06* AbsLymp-0.95* AbsMono-0.56 AbsEos-0.02* AbsBaso-0.01 ___ 03: 26PM BLOOD ___ PTT-33.4 ___ ___ 06: 40AM BLOOD Glucose-96 UreaN-6 Creat-0.6 Na-139 K-3.5 Cl-110* HCO3-22 AnGap-11 ___ 03: 26PM BLOOD Glucose-106* UreaN-7 Creat-1.0 Na-139 K-3.6 Cl-101 HCO3-25 AnGap-17 ___ 05: 50PM BLOOD Glucose-99 UreaN-6 Creat-1.0 Na-138 K-3.9 Cl-100 HCO3-26 AnGap-16 ___ 06: 40AM BLOOD Calcium-7.9* Phos-2.1* Mg-1.7 ___ 03: 26PM BLOOD Calcium-9.1 Mg-1.7 ___ 03: 32PM BLOOD Lactate-1.3 ___ 07: 50AM BLOOD Lactate-1.1 ___ 03: 54PM URINE Color-Yellow Appear-Hazy Sp ___ ___ 05: 50PM URINE Color-Yellow Appear-Hazy Sp ___ ___ 03: 54PM URINE Blood-TR Nitrite-NEG Protein-30 Glucose-NEG Ketone-40 Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-MOD ___ 05: 50PM URINE Blood-NEG Nitrite-NEG Protein-100 Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-NEG pH-7.5 Leuks-LG ___ 03: 54PM URINE RBC-6* WBC-27* Bacteri-FEW Yeast-NONE Epi-15 ___ 05: 50PM URINE RBC-10* WBC-82* Bacteri-FEW Yeast-NONE Epi-60 ___ 3: 54 pm BLOOD CULTURE #2. Blood Culture, Routine (Pending): ___ 3: 54 pm URINE **FINAL REPORT ___ URINE CULTURE (Final ___: NO GROWTH. <MEDICATIONS ON ADMISSION> Cipro started ___ <DISCHARGE MEDICATIONS> 1. Acetaminophen ___ mg PO Q6H: PRN Pain, Fever Do not exceed more than 4,000mg in 24 hours RX *acetaminophen 500 mg ___ tablet(s) by mouth q6h prn Disp #*50 Tablet Refills: *1 2. Docusate Sodium 100 mg PO BID: PRN Constipation RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day Disp #*50 Capsule Refills: *1 3. Ibuprofen 600 mg PO Q6H: PRN Pain Take with food RX *ibuprofen 600 mg 1 tablet(s) by mouth q6h prn Disp #*50 Tablet Refills: *1 4. Ciprofloxacin HCl 500 mg PO Q12H RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth twice a day Disp #*20 Tablet Refills: *0 <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 postpartum service for pyelonephritis. You were given IV antibiotics and have done very well. The team feels as though you are safe to go home on oral antibiotics. Please follow the instructions below. Take antibiotics as prescribed. Do not drive while taking Percocet Do not take more than 4000mg acetaminophen (APAP) in 24 hrs Do not take more than 2400mg ibuprofen in 24 hrs Please call the on-call doctor at ___ if you develop shortness of breath, dizziness, palpitations, fever of 101 or above, abdominal pain, heavy vaginal bleeding, nausea/vomiting, depression, or any other concerns.
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Ms ___ presented on ___ 5 weeks status post an uncomplicated vaginal delivery for pyelonephritis with a fever of 102 at home. She was admitted to the postpartum service for observation and IV ceftriaxone. Urine culture on ___ showed evidence of e coli, sensitive to ceftriaxone. While in the hospital patient's pain was controlled with PO acetaminophen and ibuprofen, and she tolerated a regular diet. She was administered IV ceftriazone 1g q24 hours. She spiked a fever on ___. Her first afebrile was on ___ at ___. . Her WBC trended down from 9.3 to 4.3. On ___, patient was feeling well and had been afebrile for 24 hours. She was tolerating PO and voiding without issue. She was transitioned to oral cipro and discharged home in stable condition with a 10 day cipro 500 BID antibiotic prescription. She had outpatient follow up scheduled.
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11007695-DS-15
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> PPROM <MAJOR SURGICAL OR INVASIVE PROCEDURE> cesarean delivery <HISTORY OF PRESENT ILLNESS> ___ yo G1 at ___ GA admitted with PPROM, confirmed on ___. <PAST MEDICAL HISTORY> denies <SOCIAL HISTORY> ___ <FAMILY HISTORY> NC <PHYSICAL EXAM> on arrival VSS, afebrile well-appearing abd soft, NT, gravid <PERTINENT RESULTS> ___ 02: 09PM BLOOD WBC-12.8* RBC-4.33 Hgb-12.7 Hct-36.5 MCV-84 MCH-29.4 MCHC-34.9 RDW-13.6 Plt ___ <MEDICATIONS ON ADMISSION> PNV <DISCHARGE MEDICATIONS> 1. Breast Pump Baby premature in NICU 2. Docusate Sodium 100 mg PO BID: PRN Constipation RX *docusate sodium [Col-Rite] 50 mg 1 capsule(s) by mouth twice a day Disp #*30 Capsule Refills: *0 3. Ibuprofen 600 mg PO Q6H: PRN Pain RX *ibuprofen 600 mg 1 tablet(s) by mouth every six (6) hours Disp #*45 Tablet Refills: *0 4. Oxycodone-Acetaminophen (5mg-325mg) ___ TAB PO Q3H: PRN Pain RX *oxycodone-acetaminophen [Endocet] 5 mg-325 mg ___ tablet(s) by mouth every four (4) hours Disp #*20 Tablet Refills: *0 5. Sertraline 75 mg PO DAILY <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> preterm premature rupture of membranes chorioamnionitis cesarean delivery liveborn male infant <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> see printed instructions
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Ms. ___ was admitted on ___ with confirmed PPROM at 31 weeks gestational age. She was given betamethasone for fetal lung maturation, and latency antibiotics. On ___ she developed clinical chorioamnionitis with maternal and fetal tachycardia, fundal tenderness and fever. She went into preterm labor as a consequence. Breech presentation was confirmed and she underwent primary low transverse c-section. Please refer to operative note for full details. The male infant was admitted to the NICU given prematurity. Post-operatively, she was started on ampicillin, gentamicin and clindamycin. She continued to have fevers within the first 24 hours and was continued on antibiotics for 48 hours afebrile. She was discharged on ___ in good condition.
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11007695-DS-16
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> Fever <MAJOR SURGICAL OR INVASIVE PROCEDURE> None <HISTORY OF PRESENT ILLNESS> ___ yo ___ s/p primary LTCS on ___ for chorioamnionitis and breech presentation after being admitted on ___ with PPROM at 31 weeks, presents on day of discharge back to triage with fever at home to ___. Patient had been treated with amp, gent, and clinda x48 hours afebrile postpartum as she had evident chorio prior to delivery (maternal and fetal tachycardia, fundal TTP, fever) and continued to spike to temps of 101 in the immediate 24 hour PP period. However, abx were discontinued after 48 hours afebrile and she was discharged in good condition to home today. She noted temp at home to 103 and malaise this afternoon. She denies increased abd pain, urinary or bowel sx (no diarrhea), no CP/SOB/cough, no leg pain, no breast symptoms (is pumping). <PAST MEDICAL HISTORY> Ob hx: primary LTCS at ___ as noted Gyn hx: no abnl Paps/fibroids PMHx: denies PSHx: breast reduction <SOCIAL HISTORY> ___ <FAMILY HISTORY> NC <PHYSICAL EXAM> on admission: 2200 T 103.0, HR 107, BP 152/80 2230 T 99.2, HR 97, BP 133/80 NAD but appears flushed, feels warm regular rhythm, tachycardia lungs CTAB throughout, good air movement, no w/r/r abd soft, NT, ND, no R/G, no fundal TTP legs no edema, erythema or TTP back ? mild left CVAT vs MSK breasts symmetric, no erythema or TTP incision well-healing s/p staples, minimal erythema around suture insertion sites but no e/o cellulitis <PERTINENT RESULTS> ___ 08: 19PM BLOOD WBC-11.5* RBC-4.18* Hgb-12.2 Hct-35.8* MCV-86 MCH-29.2 MCHC-34.2 RDW-13.6 Plt ___ ___ 08: 19PM BLOOD Neuts-87.8* Lymphs-9.7* Monos-2.2 Eos-0.1 Baso-0.2 ___ 09: 00PM BLOOD Glucose-90 UreaN-15 Creat-0.5 Na-135 K-4.6 Cl-94* HCO3-27 ___ CT abd/pelvis: 1. No evidence of significant pelvic free fluid or abscess formation. 2. Nonspecific hypodense area with surrounding hyperemic area overlying the lower uterine incision. This may be post-operative or related to a fibroid within the region of the incision. 3. Other rounded hypoattenuated foci within the uterus, some partially exophytic and others intramural. These most likely represent fibroids. 4. Limited evaluation of the gonadal and pelvic veins, however, no evidence of pelvic thrombophlebitis. <DISCHARGE INSTRUCTIONS> see printed instructions
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Ms. ___ was admitted to the postpartum service with fevers. She was initially started on IV ampicillin, gentamicin and clindamycin. Her initial laboratory results were notable for WBC of 11.5 with a leftward shift. On hospital day 2, ___ blood cultures and her urine culture were positive for gram negative rods and further speciation grew out e. coli. This was discussed with ID who recommended changing her antibiotics to ceftriaxone and clindamycin. When her urine cultures grew E. Coli that was sensitive to ceftriaxone, ID recommended a 14d course of ceftriaxone. A midline was placed and on hospital day 4, she was discharged home in stable condition to complete a 14 day course of ceftriaxone. During her hospital stay, she was maintained on labetolol 300mg bid for her chronic hypertension. Discharge Medications: 1. CeftriaXONE 2 gm IV Q24H RX *ceftriaxone 2 gram 2 gm IV q24 hours Disp #*11 Each Refills:*0 2. Heparin Flush (10 units/ml) 2 mL IV ONCE For Midline Insertion Duration: 1 Doses 3. Labetalol 300 mg PO BID RX *labetalol 100 mg 3 tablet(s) by mouth twice daily Disp #*90 Tablet Refills:*1 4. Sertraline 75 mg PO DAILY Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: E. coli bacteremia and urinary tract infection Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___
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11007954-DS-7
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> chronic HTN with preeclampsia severe by BP and ___ <MAJOR SURGICAL OR INVASIVE PROCEDURE> induction of labor iv magnesium for seizure prophylaxis primary cesarean section cardiac telemetry <HISTORY OF PRESENT ILLNESS> ___ G3P0 @ 23w4d with IVF pregnancy presents from the ___ for episode of dizziness and tachycardia to 130's noted there. She reports leaving work this afternoon and experiencing an episode of 'feeling faint' and dizzy while walking to her car after work. This occurred suddenly ___ after she rose from a seated position and went to her car. Once she was in her car and seated, she began to feel improved and felt well enough to drive to the ___ for her scheduled ultrasound. She denies CP and chest tightness during this episode. She does not believe she blacked out, but is unsure of this. She denies any dizziness, CP, or SOB currently. Reports that over the past 3 weeks she has had worsening dyspnea on exertion - could previously walk up the stairs at work without difficulty, and now she must take a break once she reaches the top of the stairs. Also notes a recent dx of ? asthma, and has been wheezing. Does not use an inhaler and denies allergies. Denies orthopnea, uses CPAP. Had similar complaint at the beginning of pregnancy and was seen in the ED for workup on ___. At that time, troponins were negative, D-Dimer was elevated, and a CT was negative for PE. +AFM. Denies VB, LOF. Denies HA, visual changes, RUQ pain. PNC: Records pending *) Dating: ___ ___ *) Labs: Rh neg/Ab neg *) Routine: LR NIPT *) U/s ___ for AMA: 331gm *) Issues: * cHTN * AMA * IVF pregnancy from ___ egg donor <PAST MEDICAL HISTORY> Depression CCY ___ <SOCIAL HISTORY> ___ <FAMILY HISTORY> NC <PHYSICAL EXAM> VSS Gen: NAD, obese CV: RRR Lungs: CTA Abd: soft, non-tender, incision c/d/I Ext: 1+ pitting edema <PERTINENT RESULTS> ___ 12: 53PM URINE HOURS-RANDOM CREAT-119 TOT PROT-9 PROT/CREA-0.1 ___ 12: 53PM URINE COLOR-Yellow APPEAR-Clear SP ___ ___ 12: 53PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 LEUK-NEG ___ 12: 53PM URINE RBC-1 WBC-1 BACTERIA-FEW YEAST-NONE EPI-<1 ___ 12: 53PM URINE AMORPH-RARE ___ 12: 53PM URINE MUCOUS-RARE ___ 12: 52PM CREAT-0.6 ___ 12: 52PM estGFR-Using this ___ 12: 52PM ALT(SGPT)-18 AST(SGOT)-24 ___ 12: 52PM URIC ACID-4.6 ___ 12: 52PM WBC-8.9 RBC-3.27* HGB-9.8* HCT-30.1* MCV-92 MCH-30.0 MCHC-32.6 RDW-15.8* RDWSD-52.8* ___ 12: 52PM PLT COUNT-280 <MEDICATIONS ON ADMISSION> PNV <DISCHARGE MEDICATIONS> 1. HYDROmorphone (Dilaudid) 4 mg PO Q4H: PRN pain RX *hydromorphone 2 mg ___ tablet(s) by mouth four times a day Disp #*50 Tablet Refills: *0 2. Ibuprofen 600 mg PO Q6H: PRN pain RX *ibuprofen 600 mg 1 tablet(s) by mouth four times a day Disp #*50 Tablet Refills: *1 <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> pre ecclampsia, severe elderly primigravida post dates pregnancy arrest of dilatation of labor morbid obesity sleep apnea <DISCHARGE CONDITION> good <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> rest. no heavy lifting, exercise,baths for 4 weeks
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The patient is a ___ G2 P0 who presented to labor and delivery at 41 weeks for a postdates induction of labor and a diagnosis of chronic hypertension. The patient was admitted with an unfavorable cervix and was induced with Cytotec and Pitocin. During her labor course, she progressed to 5 cm with spontaneous rupture of membranes at approximately 2 a.m. on the day of surgery. She failed to make any cervical change for 10 hours on Pitocin, had an IUPC placed that demonstrated inadequate contractions. Additionally, she was noted to have blood-tinged urine and severe range blood pressures with systolics in the 180s and diastolics in the 80-120s. Given these concerning developments, she underwent an evaluation of superimposed preeclampsia with severe features. Laboratory analysis confirmed the diagnosis with an elevation in her creatinine from 0.6 baseline, on admission to the hospital, to 1.2 on the morning prior to surgery. We discussed the diagnosis of preeclampsia with severe features and the recommendation for magnesium as well as expediting delivery. Given her stalled labor, cesarean section was discussed. We discussed the risks of surgery including bleeding, infection, injury to surrounding organs, including bowel, bladder, blood vessels, ureters, nerves, and fetus as well as blood clots, the risk of blood transfusion, and the risk of hysterectomy and very rarely death. We discussed the need for a possible repair of any injuries and subsequent surgeries to do so. We reviewed that we could attempt to continue trying to get her into labor; however, after 10 hours of no cervical change on Pitocin with ruptured membranes at 5 cm, we discussed that it was unlikely that she would progress quickly and that her preeclampsia may worsen and her kidney injury may be exacerbated prior to the delivery. Given all of this, the patient agreed to a cesarean delivery. Her creatinine was trended postpartum and trended down. She received magnesium for 24 hours postpartum. Her blood pressures remained in normal to mild range. She received heparin 5000 BID for prophylaxis and was maintained on telemetry with CPAP for sleep apnea. She was discharged on ___ in stable condition with outpatient follow-up scheduled.
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| 482
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11008409-DS-17
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> vaginal bleeding <MAJOR SURGICAL OR INVASIVE PROCEDURE> None <HISTORY OF PRESENT ILLNESS> ___ ___ at 28w4d with known complete previa presenting with vaginal bleeding for past 4 days. Pt had initially presented on ___ at 28w0d with VB after intercourse (stated she was unaware of contraindication). Had no blood visible on SSE and closed cervix. Pt recommended inpatient observation, however she declined admission at that time. Reports that she continued have vaginal spotting of bright red blood on toilet paper after voiding and saturating toilet paper in underwear (does not wear pads). Reports that today her VB was heavier with 3 dark red clots (largest one dime sized, other two pea sized). Has not had intercourse since ___. Denies any abdominal trauma or pain. Reports dizziness that has been unchanged for past month. Otherwise denies HA, CP, SOB, palpitations, fevers/chills. Reports CTX that will occur sporadically every few hours and are not painful. Denies LOF. Reports active FM. Had HA today that went away without medication. Denies any issues with BP this pregnancy. <PAST MEDICAL HISTORY> PNC: - ___ ___ by LMP ___ c/w 13w US - Labs ___ unknown - NG/CT/trich neg (___) - Screening: listed below - FFS normal - GTT 124 - U/S (___): 748g, 53%, complete placenta previa - Issues *) ERA: Increased risk of Down Syndrome (1 in 154), low ___ ___ Mom), s/p genetics consult, NT 1.1 mm (wnl), ___ with FISH: normal XY karyotype, neg fragile X *) anemia: Hct 31.5 (___), taking PO iron OBHx: - 1 term SVD at 37w, ~5#, son ___ - 1 preterm SVD at 36w after PTL (denies PPROM, VB), ~5# per pt, daughter, ___ (***not on IM progesterone this pregnancy***) - 9 TABs (9 D&Cs) GynHx: - h/o ___ ASCUS +HPV, ___ ECC benign - h/o possible PID in ___ - h/o endometriosis - denies STIs, including HSV - Denies history of ovarian cysts, fibroids PMH: +PPD (unknown if had CXR per pt), asthma (well controlled, last inhaler use ___ yrs ago) PSH: 9 D&Cs, breast augmentation, liposuction, LSC cholecystectomy <SOCIAL HISTORY> ___ <FAMILY HISTORY> non-contributory <PHYSICAL EXAM> On Discharge: 24 HR Data (last updated ___ @ 2317) Temp: 98.2 (Tm 98.4), BP: 104/66 (103-111/66-68), HR: 64 (64-84), RR: 18, O2 sat: 99% (98-99), O2 delivery: RA, FHR: 140-150 (140-150) Gen: [x] NAD Resp: [x] No evidence of respiratory distress Abd: [x] soft [x] non-tender Ext: [x] no edema [x] non-tender Date: ___ Time: 1200 FHT: 145/mod var/+accels/-decels, AGA Toco: flat <PERTINENT RESULTS> Labs on Admission: ___ WBC-14.0 RBC-3.19 Hgb-9.7 Hct-29.4 MCV-92 Plt-328 ___ URINE bnzodzp-NEG barbitr-NEG opiates-NEG cocaine-NEG amphetm-NEG oxycodn-NEG mthdone-NEG R/O GROUP B BETA STREP (Final ___: POSITIVE FOR GROUP B BETA STREPTOCOCCI <MEDICATIONS ON ADMISSION> albuterol PRN <DISCHARGE MEDICATIONS> albuterol PRN <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> Placenta previa with bleeding in the third trimester <DISCHARGE CONDITION> Stable but patient leaving against medical advice in the context of her first bleed with a complete placenta previa <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> It is recommended that you remain hospitalized. If you choose to leave, you do so against medical advice. Please return immediately if you have any additional bleeding, contractions, leakage of fluid, lightheadedness or dizziness, or change in mental status. Follow up tomorrow for your previously scheduled ___ appointment.
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Ms. ___ was admitted to the hospital for observation after an episode of vaginal bleeding in the setting of a known complete previa. Urine toxicology screen was negative. She received a course of betamethasone for lung maturity and was seen by the NICU and Maternal Fetal Medicine. On HD#5, patient decided to leave against medical advice to return home to care for a sick child. The medical team recommended ongoing inpatient hospitalization and counseled her to remain inpatient for ___ days following resolution of the bleeding. The risks of maternal and fetal morbidity and mortality resulting from a potentially catastrophic bleed outside the hospital were reviewed and patient noted understanding.
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11008409-DS-18
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> vaginal bleeding <MAJOR SURGICAL OR INVASIVE PROCEDURE> none <HISTORY OF PRESENT ILLNESS> ___ yo G12P1192 at ___ who presents with 2 day history of intermittent bleeding in the setting of known complete placenta previa. This is the patient's third episode of bleeding. Pt states that she has not had any recent trauma or illnesses, no F/C, no N/V/D. She has been moving some furniture around this past weekend (but no heavy lifting). Nothing in the vagina since diagnosis of complete previa. She states that starting yesterday she noticed bright red blood with wiping and since then has passed intermittent dark red/brown clots (in photos provided by patient approximately 3cm x 2cm in size). She denies any LOF, ctx; +AFM. Pt was previously seen in triage from ___ and declined admission at that time. She was then admitted from ___ with her second bleed. At that time she left against the medical advice of remaining inpatient for ___ days from her last bleed. She was made BMZ complete on ___ during this admission. <PAST MEDICAL HISTORY> PNC: - ___ ___ by ___ ___ c/w 13w US - Labs ___ positive - NG/CT/trich neg (___) - Screening: listed below - FFS normal - GTT 124 - U/S (___): 1318g 56th%, complete anterior placenta - Issues *) ERA: Increased risk of Down Syndrome (1 in 154), low ___ ___ Mom), s/p genetics consult, NT 1.1 mm (wnl), ___ with FISH: normal XY karyotype, neg fragile X *) anemia: Hct 29.4 (___), taking PO iron OBHx: G12P1192 - 1 term SVD at 37w, ~5#, son ___ - 1 preterm SVD at 36w after PTL (denies PPROM, VB), ~5# per pt, daughter, ___ (***not on IM progesterone this pregnancy***) - 9 TABs (9 D&Cs) ***do not mention to patient as it brings up negative emotions *** GynHx: - h/o ___ ASCUS +HPV, ___ ECC benign - h/o possible PID in ___ - h/o endometriosis - denies STIs, including HSV - Denies history of ovarian cysts, fibroids PMH: +PPD (unknown if had CXR per pt), asthma (well controlled, last inhaler use ___ yrs ago) PSH: 9 D&Cs, breast augmentation, liposuction, LSC cholecystectomy <SOCIAL HISTORY> ___ <FAMILY HISTORY> non-contributory <PHYSICAL EXAM> On admission: ___ 19: 50BP: 101/63 (70) ___ ___: 92 ___ 19: 51Temp.: 97.3°F ___ 19: 51Resp.: 16 / min Gen: A&O, comfortable Abd: soft, gravid, nontender, no fundal TTP Ext: non-tender, no edema SSE: os visually closed, small 1.5cm streak of dark red blood from the vault, no active bleeding, no pooling Toco flat FHT 135/moderate variability/+accels/-decels TAUS: vertex, MVP 3.8cm On discharge: Gen: appears comfortable, NAD VS: 98.5, 96/57, 77, 16, O2 98% Abd: soft, gravid, NT Ext: no calf tenderness <PERTINENT RESULTS> ___ WBC-17.6 RBC-3.27 Hgb-9.9 Hct-29.8 MCV-91 Plt-395 ___ ___ PTT-25.3 ___ ___ URINE Blood-TR* Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG ___ URINE RBC-2 WBC-1 Bacteri-FEW* Yeast-NONE Epi-2 ___ URINE bnzodzp-NEG barbitr-NEG opiates-NEG cocaine-NEG amphetm-NEG oxycodn-NEG mthdone-NEG ___ OTHER BODY FLUID CT-NEG NG-NEG SMEAR FOR BACTERIAL VAGINOSIS (Final ___: GRAM STAIN NEGATIVE FOR BACTERIAL VAGINOSIS. YEAST VAGINITIS CULTURE (Preliminary): URINE CULTURE (Pending): <MEDICATIONS ON ADMISSION> Albuterol prn <DISCHARGE MEDICATIONS> Albuterol prn <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> pregnancy at 30w2d placenta previa vaginal bleeding <DISCHARGE CONDITION> stable <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> You were admitted to the antepartum service for observation after an episode of vaginal bleeding. Your bleeding resolved and fetal testing was reassuring. It was strongly recommended that you remain hospitalized for at least 5 days to monitor for additional bleeding. However, you opted to leave Against Medical Advice. Please maintain pelvic rest (nothing in the vagina) and avoid strenuous activity.
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___ yo ___ with known complete previa admitted at 30w2d with her third episode of bleeding. On admission, she was hemodynamically stable without any active bleeding. She had no evidence of preterm labor and fetal testing was reassuring. She was already betamethasone complete as of ___. She was transferred to antepartum for observation. On HD#2, her bleeding had resolved. Ultrasound in the ___ was reassuring, although showed a persistent complete previa. Ms ___ opted to leave the hospital against medical advice despite the strong recommendation for inpatient observation for at least 5 days. She was given strict precautions and will have close outpatient follow up.
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11008409-DS-19
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> vaginal bleeding, known previa <MAJOR SURGICAL OR INVASIVE PROCEDURE> none <HISTORY OF PRESENT ILLNESS> ___ G12P2 at 33w0d in pregnancy complicated by known placenta previa with three prior bleeding events. Patient reports she felt rectal pressure at 0200, went to bathroom and began to pass bright red blood after straining. Bleeding has continued at slower rate since intial gush. Patient reports crampy abdominal pain for the last week. Good fetal movement this AM. Last PO at 0000 on ___ ROS negative for f/c/l/d/n/v. No urinary sx. No lower extremity swelling or discomfort. <PAST MEDICAL HISTORY> PNC: - ___ ___ by LMP ___ c/w 13w US - Labs ___ positive - NG/CT/trich neg (___) - Screening: listed below - FFS normal - GTT 124 - U/S (___): 1318g 56th%, complete anterior placenta - Issues *) ERA: Increased risk of Down Syndrome (1 in 154), low ___ ___ Mom), s/p genetics consult, NT 1.1 mm (wnl), ___ with FISH: normal XY karyotype, neg fragile X *) anemia: Hct 29.4 (___), taking PO iron OBHx: ___ - 1 term SVD at 37w, ~5#, son ___ - 1 preterm SVD at 36w after PTL (denies PPROM, VB), ~5# per pt, daughter, ___ (***not on IM progesterone this pregnancy***) - 9 TABs (9 D&Cs) ***do not mention to patient as it brings up negative emotions *** GynHx: - h/o ___ ASCUS +HPV, ___ ECC benign - h/o possible PID in ___ - h/o endometriosis - denies STIs, including HSV - Denies history of ovarian cysts, fibroids PMH: +PPD (unknown if had CXR per pt), asthma (well controlled, last inhaler use ___ yrs ago) PSH: 9 D&Cs, breast augmentation, liposuction, LSC cholecystectomy <SOCIAL HISTORY> ___ <FAMILY HISTORY> non-contributory <PHYSICAL EXAM> Gen: NAD Abd: soft, gravid, NT Ext: no calf tenderness <PERTINENT RESULTS> ___ 02: 33AM ___ ___ 02: 33AM ___ PTT-25.5 ___ ___ 02: 33AM PLT COUNT-355 ___ 02: 33AM WBC-18.8* RBC-3.35* HGB-10.2* HCT-30.2* MCV-90 MCH-30.4 MCHC-33.8 RDW-14.3 RDWSD-46.6* <MEDICATIONS ON ADMISSION> albuterol PRN <DISCHARGE MEDICATIONS> 1. Prenatal Vitamins 1 TAB PO DAILY <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> Pregnancy at 33 weeks. Placenta Previa, Vaginal Bleeding <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> You have been admitted for vaginal bleeding and known placenta previa and it has been recommended that you remain in the hospital. You have elected to leave. Please return with vaginal bleeding, decreased fetal movement, contractions, abdominal pain or fluid loss.
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___ yo G12P1192 with known complete previa admitted at 33w1d with her fourth episode of bleeding. On admission, she was hemodynamically stable without any active bleeding. She had no evidence of preterm labor and fetal testing was reassuring. She was made rescue BMZ and received her second dose on ___ @0430. She was transferred to ___ for observation. On HD#2, her bleeding had resolved. Ultrasound in the ___ was reassuring, although showed a persistent complete previa. Ms ___ opted to leave the hospital against medical advice despite the strong recommendation for inpatient observation for at least 5 days. She was given strict precautions and will have close outpatient follow up.
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11008720-DS-12
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> Pelvic pain <MAJOR SURGICAL OR INVASIVE PROCEDURE> Exam under anesthesia with IUD removal <HISTORY OF PRESENT ILLNESS> ___ G2P1 presents with intermittent severe lower abdominal pain x ___ weeks. The pain is described as shooting, with intense cramping - "it feels like labor". She sometimes has nausea associated with spells of the pain. She did not take anything at home for the pain. She had been coping with pain at home, but presented on ___ to the ___ after having diarrhea ___ loose BMs) and a fever to 101.2 at home with myalgias and chills. In the ___, she was told that she had an elevated WBC. A CT was done and demonstrated the IUD in the R uterine fundal myometrium. She was given Ancef and Flagyl for concern of cecal thickening and ? bowel involvement. She also got 10mg morphine and 4mg zofran. She was then transferred to ___ for GYN evaluation. Here she feels that her pain has been better, but during our conversation it was coming back. She received 1mg dilaudid with good relief. She reports that the IUD was placed in ___. She says that the placement was "awful" and receieved no local anesthesia. She had pelvic pain occasionally since then that was evaluated by her GYN. She reports several normal pelvic ultrasounds by her primary GYN that demonstrated the IUD to be in the correct position. She sees Dr. ___ in ___ (affiliated with ___). <PAST MEDICAL HISTORY> OB/GYN Hx: TAB/D+C ___, SVD term c/b manual placental removal and PPH (no blood transfusion). Denies abnormal paps or STIs. Had an operative LSC at ___ for an ovarian cyst and ? "scar tissue". Denies h/o endometriosis. PMH: Migraines, ADHD PSH: D+E, LSC ovarian cystectomy, L hip arthroscopy for labral tear, wisdom teeth on R, thumb surgery <SOCIAL HISTORY> ___ <FAMILY HISTORY> Not available <PHYSICAL EXAM> ___ by Dr. ___: T 97.1 HR 99 BP 112/91 RR 18 O2sat 97% (100.1 at ___ BP max 140/98 NAD RRR CTAB Abdomen soft, + active BS, very tender to palpation in certral lower abdomen. + voluntary guarding, no rebound. Pelvic: Vagina and cervix normal. No strings visualized in os. Cervix parous appearing. Attempted to open cervical os by placing ___ clamp in os and opening blades, but pt did not tolerate this well at all. BME: Significant uterine and cervical motion tenderness. No specific adnexal masses palpated, but patient slightly less tender over adnexa than uterus. <PERTINENT RESULTS> ___ 05: 30AM BLOOD WBC-8.9 RBC-4.12* Hgb-12.6 Hct-35.2* MCV-85 MCH-30.5 MCHC-35.7* RDW-13.4 Plt ___ ___ 05: 30AM BLOOD Neuts-74.3* ___ Monos-4.1 Eos-0.4 Baso-0.6 ___ 05: 30AM BLOOD ___ PTT-28.2 ___ ___ 05: 30AM BLOOD Glucose-110* UreaN-5* Creat-0.6 Na-138 K-3.2* Cl-107 HCO3-21* AnGap-13 ___ Blood HCG-<5 <MEDICATIONS ON ADMISSION> 1. Adderal PRN 2. Ancef 3. Flagyl <DISCHARGE MEDICATIONS> 1. ibuprofen 600 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for pain. Disp: *30 Tablet(s)* Refills: *0* 2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO twice a day as needed for constipation. Disp: *30 Capsule(s)* Refills: *1* 3. oxycodone 5 mg Tablet Sig: ___ Tablets PO every ___ hours as needed for pain. Disp: *15 Tablet(s)* Refills: *0* <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> Pelvic pain <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Call your doctor for: * fever > 100.4 * severe abdominal pain * difficulty urinating * vaginal bleeding requiring >1 pad/hr * abnormal vaginal discharge * nausea/vomiting where you are unable to keep down fluids/food or your medication General instructions: * Take your medications as prescribed. * Do not drive while taking narcotics. * 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 2 weeks. * You may eat a regular diet. To reach medical records to get the records from this hospitalization sent to your doctor at home, call ___.
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Ms. ___ was admitted to the GYN service in order to have her IUD removed and make sure that it wasn't the cause of her pelvic pain and to be sure that the IUD wasn't embedded in the myometrium. She had an uncomplicated removal of her IUD, please see operative report for full details. She was afebrile during her admission with a normal white count and was not felt that antibiotics were needed. UA was not suspicious for infection. She was discharged from the hospital on hospital day 1 and post-operative day 0 and instructed to ___ with her GYN.
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11010509-DS-9
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Demerol / Morphine / Codeine <ATTENDING> ___ <CHIEF COMPLAINT> endometrial carcinoma <MAJOR SURGICAL OR INVASIVE PROCEDURE> Total abdominal hysterectomy, bilateral salpingo-oophorectomy <HISTORY OF PRESENT ILLNESS> ___ is a ___ gravida 6, para 6 woman who suffers from coronary artery disease and has previously undergone a bypass procedure. She also suffers from diabetes and hypertension. About 4 months ago, she developed a small episode of postmenopausal bleeding and did not think very much of it. She developed lower abdominal discomfort and this led to an ultrasound, which revealed an irregular endometrium. A followup study with an MRI revealed a large echogenic mass in the posterior uterus. This is a vascular mass that measures 3.8 x 3.8 x 5.4 cm. The endometrium was not clearly or definitively separate from this lesion. The left ovary was normal. The right ovary was not easily identified. On the MRI, there appeared to be invasion of more than 50% of the myometrium. There did appear to be extension of this disease to the external os. No lymphadenopathy was identified. There is left renal atrophy. She reports a little bit of bleeding since her diagnosis of an irregularity. Ms. ___ was underoing evaluation for further treatment with Dr. ___ she was presented to the ED with worsening LLQ pain and poor PO intake. She was admitted to the gynecology oncology service. <PAST MEDICAL HISTORY> type 2 diabetes, coronary artery diseases, hypertension. She had a mammogram ___ years ago and she reports having had a normal colonoscopy in ___. Past Surgical History: She had a quadruple bypass ___ years ago. She had a cholecystectomy through a large right subcostal incision. OB/GYN History: Her last menstrual cycle was ___ years ago. She denies any postmenopausal bleeding beyond that noted above. She denies any history of pelvic infections or abnormal Pap smears. <SOCIAL HISTORY> ___ <FAMILY HISTORY> She denies any family history of cancer. <PHYSICAL EXAM> PE: 96.1 132/79 81 19 97% RA GEN: NAD HEART: RRR LUNGS: CTAB ABD: Soft, NT, ND, no R/G (after morphine in ED) EXT: NT, NE <PERTINENT RESULTS> ___ 09: 50AM BLOOD WBC-12.3* RBC-3.72* Hgb-9.7* Hct-30.6* MCV-82 MCH-26.0* MCHC-31.6 RDW-14.4 Plt ___ ___ 06: 25AM BLOOD WBC-10.9 RBC-3.11* Hgb-8.4* Hct-25.6* MCV-82 MCH-26.9* MCHC-32.7 RDW-15.0 Plt ___ ___ 07: 34AM BLOOD WBC-10.7 RBC-4.13*# Hgb-11.4*# Hct-34.3*# MCV-83 MCH-27.7 MCHC-33.4 RDW-15.4 Plt ___ ___ 06: 20AM BLOOD WBC-10.7 RBC-3.82* Hgb-10.7* Hct-32.1* MCV-84 MCH-27.9 MCHC-33.2 RDW-16.0* Plt ___ ___ 09: 50AM BLOOD Glucose-166* UreaN-38* Creat-1.8* Na-138 K-5.6* Cl-105 HCO3-19* AnGap-20 ___ 06: 25AM BLOOD Glucose-128* UreaN-18 Creat-1.3* Na-139 K-4.4 Cl-107 HCO3-19* AnGap-17 ___ 07: 34AM BLOOD Glucose-164* UreaN-15 Creat-1.3* Na-141 K-3.9 Cl-107 HCO3-21* AnGap-17 ___ 07: 20AM BLOOD Glucose-144* UreaN-8 Creat-1.1 Na-138 K-4.3 Cl-105 HCO___-24 ___ CT ABDOMEN AND PELVIS WITHOUT CONTRAST. CT ABDOMEN: There is no pericardial or pleural effusion. Within the right lung base, there is a 4-mm pulmonary nodule and possibly a 2-mm pulmonary nodule in the right lower lobe and right middle lobe, respectively (2, 1). There is a large hiatal hernia. Extensive calcifications of the descending aorta and its branches are noted. Slight aneurysmal dilatation of the descending aorta measuring 2.3 x 2.5 cm (2, 26 and 200B, 27) is identified. Within the limits of a non-contrast examination, the liver, spleen are unremarkable. Patient is status post cholecystectomy. The kidneys appear atrophic, left greater than right. Possible kidney hypodensities in the right upper pole and left kidney are incompletely evaluated. There is likely bilateral parapelvic cysts. The pancreas appears atrophic. There are no pathologically enlarged mesenteric or retroperitoneal lymph nodes identified. Small bowel loops are normal in caliber and without focal wall thickening. There is no evidence of free air or free fluid. There is no evidence of obstruction. CT OF THE PELVIS: The bladder, rectum are unremarkable. Extensive diverticulosis without evidence of acute diverticulitis is noted. The uterus is enlarged for this patient's given age. Patient's known endometrial cancer is not evaluated on this type of study. There is no pelvic or inguinal lymphadenopathy identified. BONE WINDOWS: There are no suspicious lytic or sclerotic lesions identified. There are compression fractures with anterior wedging of T10 and T12, age indeterminate. Degenerative changes and osteitis condesans illei is noted at the bilateral SI joints. IMPRESSION: 1. Large hiatal hernia. 2. Vascular calcifications with slight aneurysmal dilatation of the infrarenal abdominal aorta as described above. 3. 4-mm pulmonary nodule in the right lower lobe. 4. Diverticulosis without evidence of acute diverticulitis. 5. Bilateral renal hypodensities incompletely evaluated. Non-emergent renal ultrasound is recommended. 6. Enlarged uterus. Known endometrial cancer not evaluated on this type of study. No evidence of metastatic disease. ___ Stress test: INTERPRETATION: ___ yo woman s/p CABG was referred for evaluate prior to surgery. The patient was was administered 0.142 mg/kg/min of Persantine over 4 minutes. No chest, back, neck or arm discomforts were reported by the patient during the procedure. No significant ST segment changes were noted from baseline. The rhythm was sinus with no ectopy noted. The hemodynamic response to the Persantine infusion was appropriate. Post-infusion, the patient was administered 125 mg Aminophylline IV. IMPRESSION: No anginal symptoms or ST segment changes from baseline. Nuclear report sent separately. ___nd stress perfusion images reveal uniform tracer uptake throughout the left ventricular myocardium. Gated images reveal septal dyskinesis compatible with history of prior CABG, but otherwise normal wall motion. The calculated left ventricular ejection fraction is 79% with EDV of 35 mL. IMPRESSION: 1. Normal myocardial perfusion at peak pharmacologic stress. 2. Normal left ventricular cavity size and systolic function. Evidence of prior CABG. ___ Renal US FINDINGS: Both kidneys demonstrate multiple hypoechoic lesions not meeting sonographic criteria of simple cyst. The one in the interpolar region of right kidney measures 1 x 1.2 x 1.3 cm. The larger in the lower pole measures 1.4 x 1.1 x 1.2 cm. The left kidney on the other hand is very atrophic and demonstrates a heterogeneously echogenic lesion in the interpolar region measuring 1.7 x 1.2 x 1.5 cm with internal vascularity. There is no hydronephrosis. There are no perinephric collections. The left kidney measures 8.4 cm, and the right kidney measures 4.2 cm. The bladder is partially distended and appears grossly unremarkable. IMPRESSION: Multiple renal hypoechoic lesions not meeting sonographic criteria for simple cysts. Particularly vascular hypoechoic lesion in the interpolar region of left kidney. Further characterization with MR and/or short term interval follow-up is recommended. <MEDICATIONS ON ADMISSION> Lisinopril, Metoprolol, Amlodipine, Glyburide, Protonix, Vicodin prn abd pain <DISCHARGE MEDICATIONS> 1. Hydrocodone-Acetaminophen ___ mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed. Disp: *40 Tablet(s)* Refills: *0* 2. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed. Disp: *30 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: *0* 4. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 5. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Glyburide 2.5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. Disp: *60 Tablet(s)* Refills: *0* 8. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO once a day. <DISCHARGE DISPOSITION> Extended Care Facility: ___ <DISCHARGE DIAGNOSIS> Left lower quadrant pain Endometrial cancer <DISCHARGE CONDITION> Stable <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Please call your doctor or return to the hospital if you have: -Increased pain -Inability to eat or drink because of nausea and/or vomiting -Fevers/chills -Chest pain or shortness of breath -Any other questions or concerns Other instructions: -You should not drive for 2 weeks and while taking narcotic pain medications -You can shower -You may resume your regular diet and home medications. You will need your staples removed in a week
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Ms. ___ was admitted to the gynecology oncology service with worsening left lower quadrant pain and poor PO intake in the setting of a newly diagnosed endometrial cancer. The etiology of the patient's left lower quadrant pain was unclear. Abdominal CT was unrevealing. The pain improved with Tylenol. Given the patient's multiple comorbidities including coronary artery disease, s/p CABG, T2DM and chronic renal disease with a Creatinine elevation to 1.8 and hyperkalemia on admission, medicine consultation was obtained. The patient underwent a stress test, which revealed normal myocardial perfusion at peak pharmacologic stress and normal left ventricular cavity size and systolic function. Patient was treated with Kayexalate, with improvement in hyperkalemia. The patient's creatinine improved with hydration. Renal CT revealed a nodule, for which the patient underwent an ultrasound. Renal ultrasound revealed multiple hypoechoic lesions not meeting sonographic criteria for simple cysts and further characterization with MR and/or short term interval follow-up was recommended. On hospital day # 2 the patient was noted to have a hematocrit decrease to 25.6 from 30.6 on admission. In anticipation of an upcoming surgery, the patient received 2u PRBC transfusion with an appropriate response in Hematocrit to 34. 3 On hospital day # 4 the patient underwent an uncomplicated total abdominal hysterectomy and bilateral salpingo-oophorectomy. Please see the operative report for further details. Patient's post operative course is outlined below. *) Neuro - Pain was well controlled. Patient transitioned to Vicodin prn. *) Cardiovascular: Patient continued home doses of metoprolol, amlodipine for hypertension. Blood pressures were well controlled. Lisinopril was held in the setting of pre-operative admission with hyperkalemia. Blood pressures were well controlled and the lisinopril was held perioperatively. The patient had lisinopril restarted at the time of discharge. *) Pulmonary: Two pulmonary nodules were noted on CT scan pre-operatively, which will need outpatient follow up. *) GI: Patient's diet was slowly advanced. Nutrition was consulted and ensure supplementation was started. Patient's PO intake was felt to be adequate and her nausea improved. *) FEN: Serial electrolyte panels were checked. The patient's electrolytes were repleted prn. On the day of discharge, potassium was normal. *) Endocrine: Patient received insulin sliding scale in addition to the Glyburide while inpatient. She is discharged home on her outpatient dose of Glyburide. *) Renal: Patient has a baseline chronic renal disease and will need to have outpatient follow up of the multiple renal hypoechoic lesions seen on renal ulrasound on ___. Creatinine improved significantly with hydration. Lisinopril was restarted at the time of discharge. *) Heme: Patient's hematocrit remained stable after she received 2u PRBC pre-operatively. Her post-operative hematocrit was 32.1. *) ID: On POD # 1, the patient spiked a fever to 101.0. The rest of the vital signs remained stable. Exam was notable for bilateral lower lobe crackles and the fever was attributed to atelectasis. WBC with differential was normal. Urine culture showed no growth. Incentive spirometry was strongly encouraged and physical therapy consultation was obtained. The patient was monitored. She had no further fevers. *) Prophylaxis: The patient received IV Protonix, subcutaneous heparin, and wore pneumoboots as prophylactic measures. Patient was discharged to a rehabilitation facility in stable condition on POD # 3.
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11011049-DS-18
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> novacaine / ___ <ATTENDING> ___ <CHIEF COMPLAINT> ovarian cancer s/p neoadjuvant chemotherapy <MAJOR SURGICAL OR INVASIVE PROCEDURE> total abdominal hysterectomy, bilateral salpingo-oophorectomy, debulking, and ventral hernia repair intra-operative blood transfusion <HISTORY OF PRESENT ILLNESS> Ms. ___ initially presented with abdominal pain in ___. She had an exlap at ___ in ___ for abdominal pain with a finding of volvulus. A CT scan in ___ showed abdominal and pelvic ascites and diffuse abdominal lymphadenopathy involving the periaortic lymph nodes extending into the retroperitoneum and left pelvic sidewall. She also had several enlarged left inguinal lymph nodes. She had a right sided pelvic mass measuring 4.9 x 5.6 cm. The patient self-palpated a left axillary lymph node and excision revealed nodal involvement by metastatic carcinoma with high grade features. Immunohistochemical studies demonstrated the cancer cells to be consistent with a mullerian cancer. Her CA-125 was elevated at 2750.9. She was evaluated by Gynecology Oncology and Medical Oncology. Neoadjuvant chemotherapy was advised. She underwent 3 cycles of carboplatin/paclitaxel at ___ which she tolerated well. A pre-operative CT on ___ noted a right ovarian mass and no evidence of metastatic disease. <PAST MEDICAL HISTORY> PMH: - HTN - hypothyroidism - afib (not on anticoagulation) - ovarian cancer s/p 3 cycles neoadjuvant chemo - basal cell cancer s/p excision - per ___ records, old records note a history of EtOH abuse and possible dementia PSH: - exlap for volvulus in ___ - L knee replacement - R hip replacement - b/l breast reduction surgery - appendectomy - cervical polypectomy <SOCIAL HISTORY> ___ <FAMILY HISTORY> noncontributory <PHYSICAL EXAM> On discharge, General - NAD, comfortable CV - RRR Lungs - CTAB Abd - soft, nondistended, no rebound/guarding Inc - vertical midline abdominal incision c/d/i with staples in place Ext - nontender, nonedematous <PERTINENT RESULTS> ___ US ___ The left common femoral, superficial femoral, popliteal, peroneal, and posterior tibial veins all demonstrate normal compressibility, flow and augmentation were appropriate. There is normal phasicity in bilateral common femoral veins. IMPRESSION: No evidence of DVT in the left lower extremity. CT Abd/Pelvis ___ FINDINGS: No hepatic lesion is demonstrated. The hepatic and portal veins are patent. There is no intra or extrahepatic biliary dilatation. The gallbladder is unremarkable. The spleen, pancreas, adrenals, and kidneys are unremarkable. There is no ascites. No omental or peritoneal deposits are demonstrated and there is no adenopathy demonstrated within the abdomen or pelvis. The uterus is unremarkable. The left ovary is not visualized. In the right ovary there is a 1.5cm hypodense lesion that measures 37 ___. There is thinning/diastases of the rectus muscles above the umbilicus with anterior protrusion of the transverse colon and a loop of small bowel. No small or large bowel dilatation is present and there is no bowel wall thickening demonstrated. The patient has had previous right total hip arthroplasty. No osseous lesions are demonstrated. Advanced degenerative disc and facet joint changes are noted involving the lumbar spine. There is scoliosis of the lumbar spine convex to the right. IMPRESSION: 1. 1.5cm complex right ovarina mass is consistent with ovarian carcinoma. Differential diagnosis would include a hemorrhagic cyst. 2. No evidence of metastatic disease within the abdomen or pelvis. Specifically there is no ascites, omental or peritoneal deposits identified. 3. Paraumbilical hernia containing colon. ___ 11: 00AM BLOOD WBC-5.1 RBC-3.70*# Hgb-12.1# Hct-34.1*# MCV-92 MCH-32.6* MCHC-35.3* RDW-18.2* Plt ___ ___ 06: 00AM BLOOD WBC-4.1 RBC-2.71* Hgb-9.0* Hct-25.8* MCV-95 MCH-33.1* MCHC-34.8 RDW-18.6* Plt ___ ___ 11: 00AM BLOOD Glucose-110* UreaN-10 Creat-0.8 Na-142 K-4.3 Cl-106 HCO3-26 AnGap-14 ___ 11: 00AM BLOOD Calcium-9.4 Phos-4.2 Mg-1.5* ___ 11: 10AM BLOOD TSH-2.7 <MEDICATIONS ON ADMISSION> lisinopril 5 mg daily metoprolol XL 100 mg q am, 50 mg q pm lorazepam 0.5 mg q 6hr prn anxiety levothyroxine 50 mg ___ 88 mg ___, ___ zofran 4 mg q 8 hr prn nausea <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: *0 2. Hydrochlorothiazide 25 mg PO DAILY 3. Levothyroxine Sodium 88 mcg PO 2X/WEEK (___) 4. Levothyroxine Sodium 50 mcg PO 5X/WEEK (___) 5. Lisinopril 5 mg PO DAILY 6. Ibuprofen 600 mg PO Q6H: PRN pain Take with food. RX *ibuprofen 600 mg 1 tablet(s) by mouth 6 hours Disp #*60 Tablet Refills: *0 7. Acetaminophen 1000 mg PO Q6H Do not exceed 4000 mg acetaminophen in 24 hours. RX *acetaminophen 500 mg ___ tablet(s) by mouth every six (6) hours Disp #*60 Tablet Refills: *0 8. Aspirin 81 mg PO DAILY RX *aspirin [Adult Low Dose Aspirin] 81 mg 1 tablet,delayed release (___) by mouth daily Disp #*30 Tablet Refills: *6 9. Metoprolol Succinate XL 100 mg PO QAM 10. Metoprolol Succinate XL 50 mg PO QPM 11. OxycoDONE (Immediate Release) ___ mg PO Q4H: PRN pain RX *oxycodone 5 mg ___ capsule(s) by mouth 4 hours Disp #*60 Tablet Refills: *0 12. Lorazepam 0.5-1 mg PO Q6H: PRN anxiety RX *lorazepam [Ativan] 0.5 mg 1 tablet by mouth every ___ hours Disp #*20 Tablet Refills: *0 <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> total abdominal hysterectomy, bilateral salpingo-oophorectomy, debulking, and ventral hernia repair for ovarian cancer <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Dear Ms. ___, You were admitted to the gynecologic oncology service after undergoing the procedures listed below. You have recovered well after your operation, and the team feels that you are safe to be discharged home. Please follow these instructions: . * Take your medications as prescribed. * Do not drive while taking narcotics. * Do not combine narcotic and sedative medications or alcohol * Do not take more than 4000mg acetaminophen (APAP) in 24 hrs * No strenuous activity until your post-op appointment * Nothing in the vagina (no tampons, no douching, no sex) for 12 weeks. * No heavy lifting of objects >10 lbs for 6 weeks. * You may eat a regular diet . Incision care: * You may shower and allow soapy water to run over incision; no scrubbing of incision. No bath tubs for 6 weeks. * Your staples will be removed at your follow-up visit. . To reach medical records to get the records from this hospitalization sent to your doctor at home, call ___. .
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Ms. ___ was admitted to the gynecology oncology service after undergoing a total abdominal hysterectomy, bilateral salpingo-oophorectomy, debulking, and ventral hernia repair for ovarian cancer. Please see the operative report for full details. Her post-operative course is detailed as follows. Immediately postoperatively, her pain was controlled with a TAP block, IV dilaudid, and IV acetaminophen. Her diet was advanced without difficulty and she was transitioned to PO ibuprofen, acetaminophen, and oxycodone. On post-operative day #3, her urine output was adequate and she was ambulatory so her Foley catheter was removed and she voided spontaneously. On post-operative day 2, she reported to her nurse that she felt a sensation of heart palpitations. An EKG was performed which showed atrial fibrillation with a rate of 140. Her blood pressure was stable. She was placed on telemetry. She than was given 10 mg IV diltiazem, with an initial good response but her heart rate then increased again to 130s-140s. She then received 5 mg IV metoprolol and 25 mg immediate release metoprolol PO. After these medications, her heart rate decreased to the 100s-110s without any hemodynamic compromise. The cardiology service was consulted at the beginning of this episode and recommended these medical interventions. After full evaluation, they recommended continuing her on her usual home metoprolol regimen. Several doses of her usual metoprolol had been held post-operatively due to low blood pressures (holding parameters for BP <110). Three sets of cardiac enzymes were negative and her TSH was normal. After the above medications, she was rate controlled at the goal heart rate recommended by the cardiology service, <110. She returned to normal sinus rhythm by the next morning and had no further episodes of atrial fibrillation for the rest of her hospital admission. The cardiology service recommended starting 81 mg aspirin daily, which was begun while Ms. ___ was an inpatient, and discussing long-term anti-coagulation as an outpatient with her cardiologist given her CHADS2VASC score of 3. Please see written progress note from ___ in the inpatient record for details. The team contacted Ms. ___ office to inform the above information and left contact info should there be any questions. An outpatient appointment was arranged for Ms. ___ with her cardiologist after discharge and records faxed to his office after discharge. Of note, pt received heparin pre-operatively and then 40 mg of lovenox daily for DVT prevention while she was in the hospital. On post-operative day day 4, mildly asymmetric lower extremity edema was noted. The left lower extremity appeared mildly larger than the right. Her calves were non-tender, her oxygen saturation was normal, she was not tachycardic, and she had no tachycardia. The patient noted that asymmetric swelling was not abnormal for her after she had a left knee replacement. Given her post-operative state, an US of the left lower extremity was ordered which was negative for DVT. The patient was provided with ___ hose to help with her edema. 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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11016280-DS-14
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Penicillins / Bactrim / Erythromycin Base <ATTENDING> ___. <CHIEF COMPLAINT> Labial Abscess <MAJOR SURGICAL OR INVASIVE PROCEDURE> None <HISTORY OF PRESENT ILLNESS> ___ G3P1 with LMP ___ presents ___ with a right labial mass. Initially felt 5 days prior, attempted warm baths at home but mass enlarged. Unable to walk / sit. Denies fevers.Denies n/v. Patient was brought to OR for incision and drainage of abscess. A gram stain showed Gram positive cocci in clusters and pairs consistent with Staph Aureus. Cultures were sent and patient was sent home on PO Clindamycin. Initally the day following the I&D she had significant relief. However, on ___ Ms ___ began to have increased pain and fever/chills with temperatures ranging from ___ F. She was also complaining of diffuse joint pain and decreased appetite so she presented to GYN triage and was admitted for IV antibiotics. <PAST MEDICAL HISTORY> OBHx: ___ LTCS for NRFHT at term G2- R ectopic pregnancy- s/p R salpingectomy G3- L ectopic pregnancy - s/p L salpingectomy GynHx: regular cycles, remote h/o Chlamydia s/p tx PMH: anemia PSH: C/S x 1, b/l salpingectomy <SOCIAL HISTORY> ___ <FAMILY HISTORY> NC <PHYSICAL EXAM> 0)99.3, 81, 117/73 (recent tylenol) Gen: NAD CV: RRR no m/g/r Chest: CTAB EGBUS: R labia with 4 cm x 2 cm area of firmness. + R inguinal LAD. Sutures in place. No drainage. No obvious fluctuance. <PERTINENT RESULTS> ___ 04: 59PM WBC-6.3 RBC-4.28 HGB-11.5* HCT-36.0 MCV-84 MCH-26.9* MCHC-32.0 RDW-13.4 <MEDICATIONS ON ADMISSION> Clinda, Percocet <DISCHARGE MEDICATIONS> 1. Oxycodone-Acetaminophen ___ mg Tablet Sig: ___ Tablets PO Q4H (every 4 hours) as needed for pain: do not exceed 4 g of acetaminphen in 24 hrs. Disp: *35 Tablet(s)* Refills: *0* 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation. Disp: *60 Capsule(s)* Refills: *0* 3. Acetaminophen 500 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain, fever: do not exceed 4 g of acetaminphen in 24 hrs. Disp: *60 Tablet(s)* Refills: *0* 4. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed for pain. Disp: *60 Tablet(s)* Refills: *0* 5. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO once a day for 7 days. Disp: *7 Tablet(s)* Refills: *0* <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> Labial abscess <DISCHARGE CONDITION> Stable <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Call your doctor for: * fever > 100.4 * severe abdominal pain * difficulty urinating * vaginal bleeding requiring >1 pad/hr * abnormal vaginal discharge * redness or drainage from incision * nausea/vomiting where you are unable to keep down fluids/food or your medication General instructions: * Take your medications as prescribed. * Do not drive while taking narcotics. * No strenuous activity, nothing in the vagina (no tampons, no douching, no sex), no heavy lifting of objects >10lbs for 6 weeks. * You may eat a regular diet. Incision care: * You may shower and allow soapy water to run over incision; no scrubbing of incision. No bath tubs for 6 weeks.
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Patient was admitted directly from GYN triage to the floor for IV antibiotics. Vancomycin was started in triage but she had a diffuse pruritic reaction, involving the entire body including face and lips, so the vancomycin was stopped. The reaction resolved with IV Benadryl. Daptomycin was chosen instead with the help of the infectious disease service. Ms ___ remained in the hospital on IV Daptomycin for two days. It was not possible to find an oral antibiotic that would empirically cover MRSA while awaiting sensitivities as she is allergic to Septra. She used hot packs on the labia. During this time she was afebrile and the swelling and pain diminished. When the sensitivities returned, the Staph infection was found to be sensitive to Levofloxacin. She was discharged home with one week of Levofloxacin.
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11017039-DS-21
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Penicillins <ATTENDING> ___. <CHIEF COMPLAINT> vaginal bleeding <MAJOR SURGICAL OR INVASIVE PROCEDURE> cesarean hysterectomy <HISTORY OF PRESENT ILLNESS> ___ G3P2 at 27w3d with a known marginal previa presents with first episode of vaginal bloody mucous discharge. She presents by ambulance. The patient reports seeing blood on toilet paper when she was wiping this morning. She has not had anything in her vagina since the diagnosis of previa, and only had a vaginal probe for her TVUS on ___. The patient denies LOF, or contractions. Reports + FM. Her U/S on ___ showed that the fetus was in complete breech with an anterior marginal previa. The EFW was 1262g at 2 lb 12 oz at the 78th%. The CVL was 4.1cm. An anterior marginal previa was again noted. Her Hct was 38.7 in ___ -> 30.2 on ___. <PAST MEDICAL HISTORY> PNC: *) Dating: ___: ___ by LMP *) Labs: O+/Ab-/RPRNR/RI/HbsAg-/HIV-/GBS unknown *) Routine: - Genetics: LR maternity 21 - U/S: nl full fetal survey, previa -> marginal previa - GLT: nl - U/S on ___ showed that the fetus was in complete breech with an anterior marginal previa. The EFW was 1262g at 2 lb 12 oz at the 78th%. The CVL was 4.1cm. An anterior marginal previa was again noted POBHx: G3P2 G1 - C/S for arrest of dilation G2 - rpt C/S G3 - current PGynHx: Denies STDs or abnl paps PMH: Asthma (last hospital visit in college for nebulizers, denies intubations) PSH: C/S x 2 <SOCIAL HISTORY> ___ <FAMILY HISTORY> non-contributory <PHYSICAL EXAM> (on admission) HR 87, BP 112/43 GENERAL: NAD PULM: no acute respiratory distress ABDOMEN: soft, gravid, NT EXTREMITIES: no c/c/e SSE: - os visualized, appears closed - thin mucousy blood in vault, dark - no active bleeding BPP by Dr. ___- 16 breech presentation BPP ___ FHT: 130s, mod variab, + acel, - decel TOCO: flat <PERTINENT RESULTS> ___ WBC-11.6 RBC-3.55 Hgb-10.3 Hct-32.2 MCV-91 Plt-218 ___ WBC-19.5 RBC-3.42 Hgb-9.7 Hct-31.2 MCV-91 Plt-254 ___ WBC-18.1 RBC-3.68 Hgb-11.0 Hct-33.8 MCV-92 Plt-153 ___ WBC-14.0 RBC-3.37 Hgb-10.1 Hct-30.8 MCV-91 Plt-145 ___ WBC-12.8 RBC-3.42 Hgb-10.2 Hct-31.2 MCV-91 Plt-132 ___ ___ PTT-27.1 ___ ___ ___ PTT-20.5 ___ ___ ___ PTT-23.3 ___ ___ ___ PTT-22.7 ___ ___ ___ PTT-24.1 ___ ___ Glu-115 BUN-8 Cre-0.4 Na-139 K-4.1 Cl-108 HCO3-21 AnGap-14 ___ Glu-91 BUN-6 Cre-0.5 Na-136 K-4.1 Cl-105 HCO3-27 AnGap-8 ___ Calcium-8.2 Phos-3.2 Mg-2.0 ___ Calcium-7.8 Phos-3.2 Mg-1.7 ___ BLOOD Type-ART pO2-205 pCO2-33 pH-7.34 calTCO2-19* Base XS--6 Intubat-INTUBATED ___ BLOOD Type-ART pO2-159 pCO2-36 pH-7.30 calTCO2-18* Base XS--7 Intubat-INTUBATED ___ BLOOD Type-ART pO2-125 pCO2-33 pH-7.34 calTCO2-19* Base XS--6 Intubat-INTUBATED Vent-CONTROLLED ___ BLOOD ___ pH-7.33 Comment-GREEN-TOP ___ BLOOD Glucose-147 Lactate-3.4 Na-134 K-3.8 Cl-110 ___ BLOOD Glucose-140 Lactate-4.5 Na-136 K-3.4 Cl-111 calHCO3-18 ___ Lactate-5.8 Na-138 K-3.7 Cl-110 calHCO3-19 ___ Lactate-4.4 ___ Lactate-2.8 ___ Hgb-8.8 calcHCT-26 ___ Hgb-8.8 calcHCT-26 ___ Hgb-10.2 calcHCT-31 ___ BLOOD freeCa-1.03 ___ BLOOD freeCa-1.00 ___ BLOOD freeCa-1.09 ___ BLOOD freeCa-1.10 MRSA SCREEN (Final ___: No MRSA isolated <MEDICATIONS ON ADMISSION> albuterol, advair, PNV, sudafed <DISCHARGE MEDICATIONS> 1. Docusate Sodium 100 mg PO BID RX *docusate sodium [Colace] 50 mg 1 capsule(s) by mouth twice a day Disp #*30 Capsule Refills: *0 2. Ibuprofen 600 mg PO Q6H: PRN pain RX *ibuprofen 600 mg 1 tablet(s) by mouth every six (6) hours Disp #*50 Tablet Refills: *0 3. Oxycodone-Acetaminophen (5mg-325mg) ___ TAB PO Q4H: PRN pain RX *oxycodone-acetaminophen [Endocet] 5 mg-325 mg ___ tablet(s) by mouth every four (4) hours Disp #*30 Tablet Refills: *0 4. Senna 8.6 mg PO BID Constipation RX *sennosides [___] 8.6 mg 1 tab by mouth twice a day Disp #*30 Tablet Refills: *0 <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> Cesarean section Supracervical hysterectomy <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> see printed instructions
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___ y/o G3P2 with a known marginal previa admitted at 27w3d after her first episode of vaginal bleeding. On admission, she was hemodynamically stable with no active bleeding. Fetal testing was reassuring. She was admitted to the antepartum course for betamethasone for fetal lung maturity and the NICU was consulted. Her bleeding resolved by HD#2. In the morning on HD#3, Ms ___ awoke with sudden onset of severe abdominal pain. She was transferred to labor and delivery and was noted to have pooling of dark red blood on speculum exam. She was started on magnesium sulfate for neuroprotection. Her pain persisted and her entire abdomen was quite tender. MFM was consulted and recommended delivery given the concern for intra-abdominal bleeding. She underwent an urgent classical cesarean section at 27w5d (on ___ and delivered a liveborn female from breech presentation weighing 1230g with apgars of 7 and 8. NICU staff was present for delivery and transferred the neonate immediately for prematurity. Of note, she had received 2 doses of betamethasone but was not yet complete at the time of delivery. Intraoperatively, there was approximately 500cc of hemoperitoneum upon entry and placenta was visible making a placenta percreta the likely diagnosis. Given the likely percreta, the decision was made to convert to a supracervical hysterectomy. Urology was consulted intra-op due to concern for bladder involvement. Please see operative reports for details. Immediately post-op, Ms ___ was admitted to the FICU for closer monitoring. *FICU Course* 37 G3P3 with 27week delivery, classical c-section with placenta increta, with cesarean hysterectomy and cystoscopy. Saw ureteral jets bilaterally without any evidence of bladder injury. EBL 3L. 2u FFP. 5u pRBCs and 1u platelets. UOP was difficult to monitor but minimal. She has a T abdominal incision. No hypotension. Patient was transferred to the FICU for postpartum hemorrhage. Extubated ___ afternoon. Patient received 1 dose of cefazolin developed facial rash (which she reports she has gotten in the past with her previous c-sections) given famotidine with resolution of symptoms. Patient remained hemodynamically stable BPs 100s-120s/50s-70s. Monitored with serial h&h checks, DIC labs, lactate. Lactate clearing 5.8->4.4->2.8. Hgb stable at 10.1, Hct 30.8, plt 218->145, PTT 27->22->24.1, fibrinogen 240->253. Patient noted to have decreased urine output, 75cc/6hr period. Given 500cc NS fluid bolus, started on maintenance fluids D51/2NS at 100cc/hr, urine ouput improved to 50cc/hr and 75cc/hr. Patient has remained hemodynamically stable, and was transferred to the floor ___ evening. *Postpartum course* Per Urology, patient had her foley for 5 days which was removed on ___ and passed her trial of void. She had her left ureteral stent removed. The rest of her postpartum stay was uncomplicated and she met her post-op milestones. Patient was discharged on POD 5.
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11017872-DS-17
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> abdominal pain likely due to ruptured hemorrhagic cyst <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, appropriately tender, no rebound/guarding Ext: no TTP <PERTINENT RESULTS> ___ 11: 59PM WBC-6.4 RBC-3.34* HGB-10.5* HCT-31.0* MCV-93 MCH-31.4 MCHC-33.9 RDW-12.0 RDWSD-40.5 ___ 11: 59PM PLT COUNT-155 ___ 08: 12PM WBC-7.0 RBC-3.51* HGB-11.1* HCT-32.9* MCV-94 MCH-31.6 MCHC-33.7 RDW-12.0 RDWSD-41.1 ___ 08: 12PM PLT COUNT-167 ___ 12: 20PM WBC-7.5 RBC-3.58* HGB-11.3 HCT-34.1 MCV-95 MCH-31.6 MCHC-33.1 RDW-11.9 RDWSD-41.2 ___ 12: 20PM NEUTS-70.4 ___ MONOS-6.5 EOS-0.1* BASOS-0.3 IM ___ AbsNeut-5.28# AbsLymp-1.68 AbsMono-0.49 AbsEos-0.01* AbsBaso-0.02 ___ 12: 20PM PLT COUNT-170 ___ 07: 58AM GLUCOSE-143* UREA N-12 CREAT-0.7 SODIUM-138 POTASSIUM-4.0 CHLORIDE-102 TOTAL CO2-23 ANION GAP-17 ___ 07: 58AM estGFR-Using this ___ 07: 58AM HCG-<5 ___ 07: 58AM URINE HOURS-RANDOM ___ 07: 58AM URINE HOURS-RANDOM ___ 07: 58AM URINE UCG-NEGATIVE ___ 07: 58AM URINE GR HOLD-HOLD ___ 07: 58AM WBC-5.1 RBC-4.41 HGB-13.8 HCT-41.9 MCV-95 MCH-31.3 MCHC-32.9 RDW-11.9 RDWSD-41.3 ___ 07: 58AM NEUTS-39.0 ___ MONOS-7.7 EOS-2.0 BASOS-0.8 IM ___ AbsNeut-1.97 AbsLymp-2.54 AbsMono-0.39 AbsEos-0.10 AbsBaso-0.04 ___ 07: 58AM PLT COUNT-204 ___ 07: 58AM URINE COLOR-Yellow APPEAR-Clear SP ___ ___ 07: 58AM URINE BLOOD-MOD NITRITE-POS PROTEIN-TR GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5 LEUK-TR ___ 07: 58AM URINE RBC-19* WBC-3 BACTERIA-FEW YEAST-NONE EPI-1 ___ 07: 58AM URINE MUCOUS-OCC <MEDICATIONS ON ADMISSION> none <DISCHARGE MEDICATIONS> 1. Acetaminophen 1000 mg PO Q6H: PRN Pain - Mild Do not exceed 4,000mg in 24 hours RX *acetaminophen 500 mg 2 tablet(s) by mouth every 6 hours Disp #*50 Tablet Refills: *0 2. Docusate Sodium 100 mg PO BID RX *docusate sodium 100 mg 1 capsule(s) by mouth twice daily Disp #*50 Capsule Refills: *0 3. Nitrofurantoin Monohyd (MacroBID) 100 mg PO Q12H Please take the full course of this medication. RX *nitrofurantoin monohyd/m-cryst 100 mg 1 capsule(s) by mouth twice daily Disp #*12 Capsule Refills: *0 4. OxyCODONE (Immediate Release) ___ mg PO Q4H: PRN Pain - Moderate Reason for PRN duplicate override: Alternating agents for similar severity Do not drink alcohol or drive. RX *oxycodone 5 mg ___ tablet(s) by mouth every 4 hours Disp #*12 Tablet Refills: *0 <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> abdominal pain likely due to ruptured hemorrhagic cyst <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Dear Ms. ___, You were admitted to the gynecology service. 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. UTI: * You were found to have a urinary tract infection. Please take the full course of your antibiotics. Call your doctor for: * fever > 100.4F * severe abdominal pain * difficulty urinating * vaginal bleeding requiring >1 pad/hr * abnormal vaginal discharge * redness or drainage from incision * nausea/vomiting where you are unable to keep down fluids/food or your medication To reach medical records to get the records from this hospitalization sent to your doctor at home, call ___.
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On ___ Ms. ___ was admitted to the Gynecology service for abdominal pain. Her CT scan showed "There is a moderate to large amount of complex pelvic free fluid. In the right adnexa, there is a heterogeneous structure measuring 6.9 x 5.2 by 5.4 cm which is predominantly nonvascular, but does show some areas of vascular flow. The right ovary is not well delineated separate from this structure. The left ovary is normal in appearance measuring 2.3 x 2.0 x 1.9 cm." Findings were concerning for a ruptured hemorrhagic cyst. She was placed NPO and given IVF. She was given IV dilaudid and oral acetaminophen for pain. UA was positive for UTI, so she was started on macrobid (antibiotics), and renal ultrasound showed no evidence of stones, masses or hydronephrosis. A urine culture and cultures for gonorrhea and chlamydia were also sent. She was monitored overnight, and her hematocrit was stable. On hospital day 1, her pain had improved and she remained afebrile with normal vital signs. Her diet was advanced and she tolerated this without nausea or vomiting. She was then discharged to home in stable condition, with outpatient follow-up as scheduled.
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11019361-DS-5
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Patient recorded as having No Known Allergies to Drugs <ATTENDING> ___ <CHIEF COMPLAINT> Patient presents for primary LTCS <MAJOR SURGICAL OR INVASIVE PROCEDURE> primary LTCS <HISTORY OF PRESENT ILLNESS> ___ yo G3 P0 @ 40 ___ wks with an unengaged vertex ___ intrauterine pregnancy with a large lower uterine segment fibroid and a cervix that is long, closed and posterior. PNC: 1) ___ ___ 2) Nl labs, Rh + GBS neg 3) FFS sig for lower uterine segment fibroid otherwise nl 4) Fibroid - 9 cm in the lower uterine segment 5) ERA - Increased risk DS 1: 299, declined amnio <PAST MEDICAL HISTORY> Ob/Gyn hx: hx of Tab x 2 without complications hx of an abnormal pap followed by normal colpo exam and subsequent pap smears . PSH: ___ - Umbilical hernia repair . PMH: Fibroids Migraines Mild asthma . All: NKDA <SOCIAL HISTORY> ___ <FAMILY HISTORY> Noncontributory <PHYSICAL EXAM> PE: Blood Pressure: 144/80. Weight (Lbs): 273. Urine Protein: 2+ (ext). Urine Glucose: 0 (ext). Urine Other: blo.tr./sg 1.030 NAD ABD: gravid, good FM Fundal Height: 41. Presentation: Vertex unengaged, cx LCP. Fetal Heart Rate: 150s. Fetal Activity: Present. <PERTINENT RESULTS> - HCT ___ 22.8-> 25.6 - Plts 248-> 222-> 336 - ALT 20-> 104->122->121-->110 - AST 34-> 146->151->144-->108 - Cr 0.6-> 0.9-> 0.7 - prot/cr 5.2 <MEDICATIONS ON ADMISSION> PNV Albuterol PRN <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: *1* 2. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for Pain. Disp: *40 Tablet(s)* Refills: *2* 3. Hydromorphone 4 mg Tablet Sig: One (1) Tablet PO Q3H (every 3 hours) as needed for pain. Disp: *60 Tablet(s)* Refills: *0* 4. Nifedipine 10 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). Disp: *30 Capsule(s)* Refills: *0* 5. Labetalol 200 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). Disp: *180 Tablet(s)* Refills: *2* <DISCHARGE DISPOSITION> Home With Service Facility: ___ <DISCHARGE DIAGNOSIS> term pregnancy s/p cesarean delivery of live male infant chronic HTN with superimposed pre-eclampsia <DISCHARGE CONDITION> stable <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> routine PP instructions
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Ms. ___ was admitted for a primary cesarian section secondary to unengaged vertex fetus with large anterior fibroid and unfavorable cervix. Her cesarian section was uncomplicated, please see the operative report for full detail. . Her postoperative course was uneventful until postoperative day 3 when she was noted to have elevated blood pressures to 160/90's with intermittent mild HA. She had no other symptoms of preeclampsia. Ms. ___ had a few elevated BP's at the end of pregnancy, her HELLP labs were within normal limits on the day of admission. Labs were rechecked and significant for elevated protein/cr ratio and elevated LFT's. She was started on labetalol which was titrated to effect. Her headaches were intermittent and always improved with tylenol. Her labs were trended daily until improvement was noted. . Blood pressures continued to be difficult to control and thus nifedipine was added to her BP regimen. She was discharged home on POD 8 in stable condition, without symptoms of preeclampsia and stable blood pressures.
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11021722-DS-2
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> "Left lowr quadrant/Pelvic pain" <MAJOR SURGICAL OR INVASIVE PROCEDURE> Transvaginal Ultrasound-guided drainage of tubo-ovarian abscess <HISTORY OF PRESENT ILLNESS> Ms. ___ is a ___ G0 who presents with left lower abdominal/pelvic pain and left lower back pain. Her left lower abdominal and pelvic pain began one week ago and is similar in character and severity to previous pain from her ovarian cysts in the past. Four days ago, she was seen in the ER for severe left lower back pain that she describes as being different from her abdominal/pelvic pain. A CT scan from the ED on Thur___ showed a soft tissue attenuated lesion in left adnexa measuring 5.7x3.9x5.6cm that could represent an adnexal mass or previously suspected hydrosalpinx. Small amount free fluid noted. Ultrasound was performed the morning of presentation which via a preliminary report showed a complex hyperemic left adnexal mass just superior and medial to the left ovary suggestive of abcess. Trace fluid in endometrial canal. +free fluid in pelvis. Right ovary normal. The patient was seen by the NP at ___ and consulted with Dr ___ prescribed ___ 500 daily and Flagyl 500 BID which she has been using since ___ for suspected PID, can't rule out ___ and was sent for TVUS. She has also been using percocet and ibuprofen about every 6 hours with relief from pain. On pelvic exam earlier this morning, she was noted to have greenish vaginal discharge. Gonorrhea and Chlamydia cultures have already been sent and are negative. Patient reports nausea and 2 episodes of emesis one week ago when her left abdominal/pelvic pain began and again four days ago when her severe left lower back pain began. Her n/v has currently subsided. She reports chills, but denies any fever. She denies any dizziness or feeling lightheaded. Denies dysuria, urinary frequency, hematuria, change in bowel movements, and BRBPR. She denies vaginal bleeding and dyspareunia. <PAST MEDICAL HISTORY> - Ovarian cysts <SOCIAL HISTORY> ___ <FAMILY HISTORY> Non-contributory <PHYSICAL EXAM> VS: 97.3 74 110/63 18 Gen: No acute distress, appears uncomfortable Cardio: Regular rate and rhythm, normal S1 and S2, no murmurs appreciated Lungs: Clear to auscultation bilaterally, no Costo-vertebral angle tenderness Abdomen: Soft, non-distended, tenderness to deep palpation in left lower quadrant. Normoactive bowel sounds. No guarding or rebound. Pelvic: Not indicated since patient had pelvic exam this morning. Per NP's report, patient had creamy discharge. No CMT, adnexal fullness and tenderness on left. Extremities: Non-tender/Non-edematous +good perfusion <PERTINENT RESULTS> Pelvic Ultrasound: Hyperemic complex left adnexal mass superomedial to the left ovary most compatible with tubo-ovarian abscess versus endometriosis. Gonorrhea and Chlamydia cultures were negative Drainage culture showed no growth <MEDICATIONS ON ADMISSION> - Levofloxacin 500mg PO daily - Flagyl 500mg PO BID <DISCHARGE MEDICATIONS> 1. ondansetron 4 mg Tablet, Rapid Dissolve Sig: One (1) Tablet, Rapid Dissolve PO Q8H (every 8 hours) as needed for nausea. Disp: *20 Tablet, Rapid Dissolve(s)* Refills: *0* 2. doxycycline hyclate 100 mg Capsule Sig: One (1) Capsule PO Q12H (every 12 hours). Disp: *27 Capsule(s)* Refills: *0* 3. Percocet ___ mg Tablet Sig: ___ Tablets PO every four (4) hours as needed for pain. Disp: *30 Tablet(s)* Refills: *0* 4. ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. Disp: *30 Tablet(s)* Refills: *1* 5. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day as needed for constipation. Disp: *20 Capsule(s)* Refills: *0* 6. metronidazole 500 mg Tablet Sig: One (1) Tablet PO twice a day. Disp: *12 Tablet(s)* 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> - Please start taking your antibiotics from tonight - Please take all your medications as prescribed - Do not drive while taking narcotics
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Ms ___ was admitted into the gynecology service for treatment of a tuboovarian abscess. It was discovered that her abscess was amenable to drainage. She was started on IV ceftriaxone, gentamicin and flagyl, which she received for 4 days in total. She underwent transvaginal ultrasound-guided drainage of the tuboovarian abscess on hospital day 3, which drained 12ml of frank pus. Her gonorrhea and chlamydia cultures came back negative. Her drainage cultures and urine cultures also came back negative. She did have a positive bacterial vaginosis smear on ___ but was already on appropriate treatment. She was discharged on hospital day 4 after being transitioned to oral antibiotics and after having been afebrile throughout her course.
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11024611-DS-12
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> undifferentiated endometrial sarcoma <MAJOR SURGICAL OR INVASIVE PROCEDURE> total abdominal hysterectomy and bilateral salpingo-oopherectomy <HISTORY OF PRESENT ILLNESS> ___ y G4P4004 presents with undifferentiated endometrial sarcoma. She began having vaginal bleeding on ___, light at first and then extremely heavy; went to urgent care at ___ and then ___ for eval; and then saw her gynecologist Dr. ___ on ___ when she had an ultrasound and EMB. Now bleeding has lessened, would soak about 2 pads per day, but changes more frequently for comfort. Never had PMB prior to this episode. Reports headache, and left leg swelling 3 weeks ago that has since resolved. She denies any early satiety, unintentional weight changes, nausea/vomiting, SOB/CP, increased abdominal girth, abdominal or pelvic pain, or change in her bowel or bladder habits. <PAST MEDICAL HISTORY> Obstetrical History: - G4P4004 - SVD x 4 Gynecologic History: - LMP at age ___ - Denies history of abnormal uterine bleeding or dysmenorrhea - Denies history of abnormal Pap tests - Denies history of pelvic infections of sexually transmitted infections - Reports history of fibroids <PAST MEDICAL HISTORY> - Meningioma s/p craniotomy ___, radiation ___, no seizures, no residual deficits, surveillance WNL - Hypertension - Hypercholesterolemia Health Maintenance: -Mammogram: ___ -Colonoscopy: no -Bone Mineral Density: ___ Past Surgical History: -Craniotomy ___ for meningioma -Varicose vein surgery <SOCIAL HISTORY> ___ <FAMILY HISTORY> Denies a known family history of breast, ovarian, uterine, cervical, or colon malignancy <PHYSICAL EXAM> Vitals: stable within normal limits General: NAD, comfortable appearing. Neuro: AxO x 3, affect appropriate. HEENT: Normocephalic, atraumatic. Sclerae anicteric. Cardiovascular: RRR, no rubs/murmurs/gallops. Pulmonary: normal rate and work of breathing, Lungs CTAB Abdomen: Normoactive bowel sounds. Soft, minimally tender to palpation, mildly-distended. No rebound/guarding. Incisions clean, dry, and intact without erythema or exudate GU: no pad in place. MSK: Lower extremities without edema, erythema, or TTP. <PERTINENT RESULTS> ADMISSION/PRE-OP LABS ___ 06: 10AM BLOOD WBC-4.4 RBC-4.10 Hgb-12.1 Hct-36.7 MCV-90 MCH-29.5 MCHC-33.0 RDW-12.5 RDWSD-40.9 Plt ___ ___ 06: 10AM BLOOD Glucose-112* UreaN-9 Creat-0.7 Na-144 K-3.6 Cl-106 HCO3-28 AnGap-10 ___ 06: 10AM BLOOD Calcium-9.5 Phos-3.5 Mg-2.0 <MEDICATIONS ON ADMISSION> 1. amLODIPine 10 mg PO HS 2. Pravastatin 40 mg PO QPM <DISCHARGE MEDICATIONS> 1. Acetaminophen ___ mg PO Q6H: PRN Pain - Mild Reason for PRN duplicate override: Alternating agents for similar severity RX *acetaminophen 500 mg ___ capsule(s) by mouth every six hours Disp #*60 Capsule Refills: *1 2. Enoxaparin Sodium 40 mg SC DAILY RX *enoxaparin 40 mg/0.4 mL 40 mg subcutaneous injection daily Disp #*24 Syringe Refills: *0 3. Ibuprofen 400 mg PO Q8H: PRN Pain - Mild RX *ibuprofen 400 mg 1 tablet(s) by mouth every 8 hours Disp #*60 Tablet Refills: *1 4. OxyCODONE (Immediate Release) 5 mg PO Q4H: PRN Pain - Severe RX *oxycodone 5 mg 1 tablet(s) by mouth every 4 horus Disp #*10 Tablet Refills: *0 5. amLODIPine 10 mg PO HS 6. Pravastatin 40 mg PO QPM <DISCHARGE DISPOSITION> Home With Service Facility: ___ <DISCHARGE DIAGNOSIS> undifferentiated uterine sarcoma <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Dear Ms. ___, . You were admitted to the gynecologic oncology service after undergoing the procedures listed below. You have recovered well after your operation, and the team feels that you are safe to be discharged home. Please follow these instructions: . * Take your medications as prescribed. We recommend you take non-narcotics (i.e. Tylenol, ibuprofen) regularly for the first few days post-operatively, and use the narcotic as needed. As you start to feel better and need less medication, you should decrease/stop the narcotic first. * Take a stool softener to prevent constipation. You were prescribed Colace. If you continue to feel constipated and have not had a bowel movement within 48hrs of leaving the hospital you can take a gentle laxative such as milk of magnesium. * Do not drive while taking narcotics. * Do not combine narcotic and sedative medications or alcohol. * Do not take more than 4000mg acetaminophen (tylenol) in 24 hrs. * No strenuous activity until your post-op appointment. * Nothing in the vagina (no tampons, no douching, no sex) for 12 weeks. * No heavy lifting of objects >10 lbs for 6 weeks. * You may eat a regular diet. * It is safe to walk up stairs. . Incision care: * You may shower and allow soapy water to run over incision; no scrubbing of incision. No bath tubs for 6 weeks. * You should remove your port site dressings ___ days after your surgery, if they have not already been removed in the hospital. Leave your steri-strips on. If they are still on after ___ days from surgery, you may remove them. * Since you have staples, you will have an appointment for them to be removed . Lovenox injections: * Patients having surgery for cancer have risk of developing blood clots after surgery. This risk is highest in the first four weeks after surgery. You will be discharged with a daily Lovenox (blood thinning) medication. This is a preventive dose of medication to decrease your risk of a forming a blood clot. A visiting nurse ___ assist you in administering these injections. . To reach medical records to get the records from this hospitalization sent to your doctor at home, call ___. . Best wishes, Your ___ GYN/Oncology Team
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Ms. ___ is a ___ year old woman who was admitted to the gynecologic oncology service after undergoing total abdominal hysterectomy and bilateral salpingo-oopherectomy for undifferentiated uterine sarcoma. Please see the operative report for full details. Her post-operative course is detailed as follows. Immediately postoperatively, her pain was controlled with a thoracic epidural catheter. Her diet was advanced without difficulty and she was transitioned to oral ibuprofen, acetaminophen, and oxycodone. On post-operative day #3, her urine output was adequate so her Foley catheter was removed and she voided spontaneously. By post-operative day 4, she was tolerating a regular diet, voiding spontaneously, ambulating independently, and pain was controlled with oral medications. She was then discharged home in stable condition with outpatient follow-up scheduled. She will remain on lovenox for DVT prophylaxis for 28 days post-operatively.
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11024831-DS-16
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> lavender (Lavandula angustifolia) / kiwi / pollen / adhesive / latex <ATTENDING> ___ <CHIEF COMPLAINT> symptomatic fibroid uterus <MAJOR SURGICAL OR INVASIVE PROCEDURE> Total abdominal hysterectomy, bilateral salpingectomy <PHYSICAL EXAM> Preoperative <PHYSICAL EXAM> WDWN woman in NAD BP: 118/80. Weight: 186 (With Clothes). BMI: 29.1. LMP: ___. ABD: soft, non-distended, non-tender uterine fundus palpable approximately 17 cm above pubic symphysis no inguinal lymphadenopathy PELVIC: normal female external genitalia BUS - wnl no perineal or perirectal lesions v/v with a normal appearing d/c, no lesions cx without CMT uterus ~ 17 cm, irregularly contoured, non-tender minimally mobile adnexa - impossible to evaluate secondary to her large pelvic/abd mass Discharge Physical Exam Vitals: VSS Gen: NAD, A&O x 3 CV: RRR Resp: no acute respiratory distress Abd: soft, appropriately tender, no rebound/guarding, incision c/d/i Ext: no TTP <MEDICATIONS ON ADMISSION> - albuterol - clobetasol - fluticasone - HCTZ - levothyroxine - iron - MVI <DISCHARGE MEDICATIONS> 1. Acetaminophen ___ mg PO Q6H: PRN Pain - Mild Do not exceed 4g in 24 hours RX *acetaminophen 500 mg 1 tablet(s) by mouth every four (4) hours Disp #*60 Tablet Refills: *1 2. Cyclobenzaprine 10 mg PO ONCE MR1 Duration: 1 Dose Do not drive or combine with alcohol. ___ cause sedation. Be cautious in combining with narcotics. RX *cyclobenzaprine 5 mg ___ tablet(s) by mouth every eight (8) hours Disp #*15 Tablet Refills: *0 3. Docusate Sodium 100 mg PO BID RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day Disp #*60 Capsule Refills: *2 4. Ibuprofen 600 mg PO Q6H: PRN Pain - Moderate Please take medication with food RX *ibuprofen 600 mg 1 tablet(s) by mouth every six (6) hours Disp #*60 Tablet Refills: *1 5. Ondansetron 4 mg PO Q8H: PRN nausea RX *ondansetron 4 mg ___ tablet(s) by mouth every 8 hours Disp #*15 Tablet Refills: *0 6. OxyCODONE (Immediate Release) ___ mg PO Q4H: PRN Pain - Severe Do not drive or operate heavy machinery while on this medication RX *oxycodone 5 mg 1 capsule(s) by mouth every four (4) hours Disp #*45 Capsule Refills: *0 7. Fluticasone Propionate 110mcg 1 PUFF IH BID 8. Hydrochlorothiazide 25 mg PO DAILY 9. Levothyroxine Sodium 137 mcg PO DAILY <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> uterine fibroids <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Dear Ms. ___, You were admitted to the gynecology service after 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. Be cautious combining narcotics and muscle relaxants as both may cause sedation. * Do not take more than 4000mg acetaminophen (APAP) in 24 hrs. * No strenuous activity until your post-op appointment. * Nothing in the vagina (no tampons, no douching, no sex) for 6 weeks. * No heavy lifting of objects >10 lbs for 6 weeks. * You may eat a regular diet. * You may walk up and down stairs. Incision care: * You may shower and allow soapy water to run over incision; no scrubbing of incision. No tub baths for 6 weeks. * If you have steri-strips, leave them on. They will fall off on their own or be removed during your followup visit. Call your doctor for: * fever > 100.4F * severe abdominal pain * difficulty urinating * vaginal bleeding requiring >1 pad/hr * abnormal vaginal discharge * redness or drainage from incision * nausea/vomiting where you are unable to keep down fluids/food or your medication To reach medical records to get the records from this hospitalization sent to your doctor at home, call ___.
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On ___, Ms. ___ was admitted to the gynecology service after undergoing a total abdominal hysterectomy and bilateral salpingectomy. Please see the operative report for full details. Her post-operative course was complicated by a short episode of lightheadedness and nausea. Orthostatics were done which were normal. The symptoms resolved spontaneously. Immediately post-op, her pain was controlled with TAP block and IV dilaudid/toradol. Her diet was advanced without difficulty and she was transitioned to PO oxycodone, ibuprofen, acetaminophen, and flexeril. On post-operative day 1, her urine output was adequate so her foley 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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11026100-DS-20
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Patient recorded as having No Known Allergies to Drugs <ATTENDING> ___. <CHIEF COMPLAINT> Abdominal pain, fever <MAJOR SURGICAL OR INVASIVE PROCEDURE> Exploratory laparotomy Bilateral salpingo-oophorectomy Lysis of adhesions <HISTORY OF PRESENT ILLNESS> ___ yo G3P2012 female presented to the ED overnight ___ with complaints of fever and abdominal pain. Starting ___, pt noted fevers with Tmax at home of 101.9. She also had nasal congestion and thought she had a cold or allergies. ___, she continued to have fevers of 101.4 and at ___ had sharp, crampy abdominal pain that felt as though she 'was having a baby.' When the pain did not resolve by ___ she came to the ED. Abdominal pain is described as sharp, crampy, intermittent, bilateral lower abdomen, radiates to back, ___. Not associated with n/v, change in appetite. Has not had recent changes in weight. No CP, SOB, cough. Has had normal bowel and bladder function. Denies hematuria, vaginal bleeding, constipation or diarrhea. Denies abnormal vaginal discharge. . She has been in the ED and has received Tylenol 1 gram @ 0200 and 0930, Morphine 2 mg 0200 and 4mg @ 0700, Motrin 800 mg @ 0930, Cipro/Flagyl x one dose. Morphine improves the pain but she continues to have the same abdominal pain. <PAST MEDICAL HISTORY> -Hepatitis C. Recent HCV viral load ___ was 5.9 million IU/mL. RUQ U/S ___ showed mild fatty infiltration. Bx ___ with chronic Hep C with increased fibrosis and inflammation. Followed by Dr. ___ per Dr. ___, pt is a non-responder to Interferon and Ribavirin. No recent use of these meds. -Asthma -Arthritis bilateral knees -Anxiety -Seasonal allergies <SOCIAL HISTORY> ___ <FAMILY HISTORY> Mother is currently hospitalized at ___ for multiple medical issues including HTN, COPD, DM, recent post-op complication. Sister has leukemia and is undergoing treatment. No FH of ovarian, uterine, cervical, breast, or colon CA. <PHYSICAL EXAM> 103.___, 69, 97/49, 18, 100% RA Gen: ___ female, lying in stretcher, comfortable and well-appearing, and able to move with ease. Lungs: CTA bilaterally, no wheezes CV: RRR, no murmurs Abd: Bowel sounds present. Soft, obese, minimal tenderness bilateral lower abdomen with deep palpation R>L with no rebound/guarding. Phannenstiel scar noted. SVE: Pt with tenderness during exam at vaginal cuff and states it elicited the same pain that she presented with. Same mild lower abd tenderness with exam R>L. Unable to palpate adnexal mass due to habitus. No vaginal cuff defect noted. <PERTINENT RESULTS> ___ 08: 50PM WBC-9.8 RBC-3.96* HGB-12.6 HCT-36.3 MCV-92 MCH-31.7 MCHC-34.6 RDW-13.5 ___ 08: 50PM PLT COUNT-138* ___ 07: 50AM URINE COLOR-Yellow APPEAR-Clear SP ___ ___ 07: 50AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-NEG ___ 01: 35AM LACTATE-1.2 ___ 01: 20AM GLUCOSE-134* UREA N-19 CREAT-0.9 SODIUM-134 POTASSIUM-5.1 CHLORIDE-102 TOTAL CO2-23 ANION GAP-14 ___ 01: 20AM ALT(SGPT)-40 AST(SGOT)-38 LD(LDH)-389* ALK PHOS-77 AMYLASE-56 TOT BILI-0.9 ___ 01: 20AM LIPASE-28 ___ 01: 20AM ALBUMIN-4.0 ___ 01: 20AM CRP-109.9* ___ 01: 20AM WBC-13.5*# RBC-4.32 HGB-12.6 HCT-38.0 MCV-88 MCH-29.2 MCHC-33.2 RDW-14.1 ___ 01: 20AM NEUTS-72.7* ___ MONOS-4.8 EOS-0.3 BASOS-0.3 ___ 01: 20AM SED RATE-20 . ___ 9: 09 pm FLUID,OTHER LEFT ADNEXAL MASS. **FINAL REPORT ___ GRAM STAIN (Final ___: 3+ ___ per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. 2+ ___ per 1000X FIELD): GRAM NEGATIVE ROD(S). REPORTED BY PHONE TO ___ @ 1: 28A ___. FLUID CULTURE (Final ___: ESCHERICHIA COLI. MODERATE GROWTH. ESCHERICHIA COLI. SPARSE GROWTH. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ESCHERICHIA COLI | ESCHERICHIA COLI | | AMPICILLIN------------ <=2 S <=2 S AMPICILLIN/SULBACTAM-- <=2 S <=2 S CEFAZOLIN------------- <=4 S <=4 S CEFEPIME-------------- <=1 S <=1 S CEFTAZIDIME----------- <=1 S <=1 S CEFTRIAXONE----------- <=1 S <=1 S CEFUROXIME------------ 4 S 4 S CIPROFLOXACIN---------<=0.25 S <=0.25 S GENTAMICIN------------ <=1 S <=1 S MEROPENEM-------------<=0.25 S <=0.25 S PIPERACILLIN---------- <=4 S <=4 S PIPERACILLIN/TAZO----- <=4 S <=4 S TOBRAMYCIN------------ <=1 S <=1 S TRIMETHOPRIM/SULFA---- <=1 S <=1 S ANAEROBIC CULTURE (Final ___: NO ANAEROBES ISOLATED. . ___ 9: 45 am STOOL CONSISTENCY: LOOSE Source: Stool. FECES NEGATIVE FOR C. DIFFICILE TOXIN BY EIA. . ___ 8: 40 pm STOOL CONSISTENCY: NOT APPLICABLE Source: Stool. FECES NEGATIVE FOR C. DIFFICILE TOXIN BY EIA. . ___ 7: 23 am STOOL CONSISTENCY: WATERY Source: Stool. FECES NEGATIVE FOR C. DIFFICILE TOXIN BY EIA. . ___ 8: 50 pm BLOOD CULTURE 1 of 2 and 2 of 2. Blood Culture, Routine (Final ___: NO GROWTH. . ___ 9: 49 pm BLOOD CULTURE Source: Venipuncture. Blood Culture, Routine (Pending): . ___ 8: 46 pm BLOOD CULTURE Source: Venipuncture. Blood Culture, Routine (Pending): . ___ 7: 50 am URINE Site: CLEAN CATCH MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION. . ___ 9: 54 pm URINE Source: ___. URINE CULTURE (Final ___: NO GROWTH. . ___ 11: 02 pm URINE Source: ___. URINE CULTURE (Final ___: NO GROWTH. . CHEST (PA & LAT) ___ 10: 44 ___ New areas of atelectasis involving the right lower lobe, right middle lobe and left lower lobe to a lesser extent, most likely related to recent surgery. No evidence of pneumonia . CT PELVIS W/CONTRAST ___ 5: 06 AM 1. Cystic, septated lesions with relatively thick walls within the adnexa. Diagnostic considerations include abnormal ovarian cysts, peritoneal inclusion cysts, hydrosalpinx or possibly pyosalpinx as superimposed infection cannot be excluded. Further evaluation with pelvic ultrasound recommended for further evaluation. 2. 4-mm right lower lobe nodule. In absence of known malignancy or risk factors, no further followup would be warranted. Otherwise, ___ year followup could be performed to document stability. . PELVIS U.S., TRANSVAGINAL ___ 6: 56 AM Complex, enlarged bilateral adnexal cystic structures. Diagnostic considerations include old hemorrhagic cysts, endometriomas, or possibly mucinous cystic neoplasm of the ovaries. MRI may be helpful for further evaluation. <MEDICATIONS ON ADMISSION> -Atrovent -Albuterol -Allergra -Ambien -Ativan prn anxiety <DISCHARGE MEDICATIONS> 1. Fexofenadine 60 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 2. Hydrocodone-Acetaminophen ___ mg Tablet Sig: ___ Tablets PO every ___ hours as needed for pain: maximum daily Tylenol (acetaminophen) is 4000mg, each Vicodin contains 500mg Tylenol (acetaminophen). Disp: *50 Tablet(s)* Refills: *0* 3. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. Disp: *60 Tablet(s)* Refills: *0* 4. Zolpidem 5 mg Tablet Sig: ___ Tablets PO HS (at bedtime) as needed. 5. 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* 6. Albuterol 90 mcg/Actuation Aerosol Sig: ___ Puffs Inhalation Q6H (every 6 hours) as needed. 7. Atrovent HFA Inhalation 8. Levofloxacin 750 mg Tablet Sig: One (1) Tablet PO once a day for 7 days. Disp: *7 Tablet(s)* Refills: *0* 9. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO every eight (8) hours for 7 days. Disp: *21 Tablet(s)* Refills: *0* <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> Bilateral infected endometriomas <DISCHARGE CONDITION> Good <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Call your doctor for: * fever > 100.4 * worsening diarrhea * severe abdominal pain * difficult urinating * vaginal bleeding requiring >1 pad/hr * redness or drainage from incision * nausea/vomiting where you are unable to keep down fluids/food or your medication . General instructions: * Take your medications as prescribed. * Do not drive while taking narcotics. * No strenuous activity, nothing in the vagina (no tampons, no douching, no sex), no heavy lifting of objects >10lbs for 6 weeks. * You may eat a regular diet. . Incision care: * You may shower and allow soapy water to run over incision; no scrubbing of incision. No bath tubs for 6 weeks. * If you have staples, they will be removed at the appointment listed below.
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Ms. ___ was admitted to the gynecology service. She was taken to the operating room on hospital day 2 and underwent exploratory laparotomy, bilateral salpingo-oopherectomy, and lysis of adhesions for bilateral infected endometriomas. Please see operative note for complete details. . Her post-operative course was characterized by the following: . 1) cardiovascular On post-operative day 2, Ms. ___ experienced some chest tightness. An EKG was obtained that showed normal sinus rhythm and no change from her prior EKG. She was saturating >95% on room air. She was transiently tachycardic to 100-105. Hct was stable at ~24. . 2) GI On post-operative day 2, Ms. ___ experienced some nausea after initially trying regular food. Her diet was restricted to sips and clears, which she tolerated well. She was eventually advanced to regular diet without further evidence of possible ileus. . On post-operative day 4, she began to have ___ watery bowel movements per day. In the setting of her fever (see below) and treatment with antibiotics, three stool samples for Clostridium difficile toxin assay was sent; they were all negative. . In light of her hepatitis C, liver function tests were obtained during this hospitalization and were normal. . 3) endocrine Ms. ___ blood glucose was elevated on post-operative day 1; her fasting glucose was 165. Fingerstick glucose was obtained until post-operative day 4; they ranged from 120s to 160s. She will need out-patient follow-up with her primary care provider for diabetes screening. . 4) ID The fluid removed from the infected endometriomas yielded pan-sensitive E. coli. Ms. ___ received ampicillin, gentamicin, and IV flagyl for 7 days after her initial regimen of IV levofloxacin and IV flagyl. She was discharged on 7 additional days of PO levofloxacin and flagyl. . Ms. ___ course was complicated by post-operative fever that persisted until post-operative day 4; she did not complain of any localizing symptoms other than diarrhea (as above). Her work-up included CBC during fever, multiple blood and urine cultures and a chest radiograph, none of which yielded any source of infection. She had no leukocytosis post-operatively. Two sets of blood cultures are still pending (no growth to date) at the time of this summary. Her vital signs otherwise remained stable throughout her hospital course. . She was discharged on hospital day 8 and postoperative day 6, afebrile for >36 hours, ambulating and urinating without difficulty, tolerating regular food, and under adequate pain control with oral medications.
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11027433-DS-17
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> shortness of breath <MAJOR SURGICAL OR INVASIVE PROCEDURE> repeat cesarean section <HISTORY OF PRESENT ILLNESS> ___ yo G4P1 at ___ with hx of severe asthma, DVT in this pregnancy who was transferred from the ED after acute asthma exacerbation. In the ED she received four nebulizer treatments (2 albuterol, 2 ipratropium). Last neb was at 1800. She received 125 mg IV methylprednisone and 2g magnesium sulfate. Since arriving to L+D she reports that her SOB has worsened and she feels increased wheezing. She also needs to sit directly straight up or her symptoms worsen. She has had cough for the last few days. She also received tamiflu and z-pack x1 in the ED. She denies chest pain, n/v, abd pain, ctx, fever, chills. + FM. <PAST MEDICAL HISTORY> PNC: - ___ ___ by ___ - Labs A-/Ab+(rhogam)/RI/RPRNR/HBsAg-/HIV-/GBS - Screening: did not have per patient - FFS (___): at 28 weeks, normal 1251 g (34.8%). - GLT: Normal - Issues *) Noncompliance: patient rescheduled multiple CMFM, NICU appt. But now s/p NICU. Never saw MFM. *) Asthma: 3 admissions in the last month, has been on steroid taper previously after admissions *) Tx of care from ___ at 34 weeks, did not bring records *) DVT left leg: on lovenox, dx ___. supposed to switch to heparin today. *) Chronic shoulder pain: on oxycodone throughout pregnancy approx 10 mg TID *) Hx of difficult intubation s/p anesthesia consult *) Juvenile RA s/p B/L hip replacement. For rLTCS OBHx: G4P1 - TAB - SAb - LTCS 5#9 GynHx: - Denies abnormal Pap, fibroids, Gyn surgery, STIs PMH: - Asthma: hx of intubation as a child. Mult admissions in the last 2 mos. - DVT: dx ___. lovenox -> heparin BID in pregnancy. - Juvenile RA: reports pericarditis as a child. s/p B/L hip replacements - DVT as above - Hx of difficult intubation during last surgery - Chronic chest/shoulder pain: on oxycodone TID PSH: - B/L hip replacement - Hernia repair as a child - Open appendectomy - Right shoulder arthroscopy <SOCIAL HISTORY> ___ <FAMILY HISTORY> NC <PHYSICAL EXAM> Physical Exam VS: T-98.3 HR-115-120 BP-128/74 RR-30 O2-95% RA Gen: A&O, comfortable CV: RRR PULM: diffuse expiratory wheezing. talking in full sentences Abd: soft, gravid, nontender Ext: no calf tenderness SVE defer Toco flat FHT 135/mod var/+accels/-decels <PERTINENT RESULTS> 10.9>12.7/36.7<267 ABG ___ at 0027: ___ on RA, lactate 3.5 (was 1.7), glucose ___ s/p methyprednisone <MEDICATIONS ON ADMISSION> PNV, lovenox (last dose ___ am), oxicodone 10 mg TID, patient reports being on steroid inhaler and albuterol inhaler at home. <DISCHARGE MEDICATIONS> 1. breast pump breast pump for poor latch use for breast milk as needed 2. Albuterol Inhaler 2 PUFF IH Q4H: PRN sob 3. Azithromycin 250 mg PO Q24H RX *azithromycin 250 mg 1 tablet(s) by mouth q day Disp #*2 Tablet Refills: *0 4. Docusate Sodium 100 mg PO BID: PRN Constipation RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice a day Disp #*30 Capsule Refills: *0 5. Ibuprofen 600 mg PO Q6H: PRN Pain RX *ibuprofen 600 mg 1 tablet(s) by mouth q 6 hours prn pain Disp #*30 Tablet Refills: *0 6. OxycoDONE (Immediate Release) ___ mg PO Q4H: PRN pain RX *oxycodone [Oxecta] 5 mg 1 tablet(s) by mouth q 4 hours prn pain Disp #*50 Tablet Refills: *0 7. PredniSONE 5 mg PO daily Duration: 3 Days Start: After 10 mg tapered dose. RX *prednisone 5 mg 6 tablet(s) by mouth once a day Disp #*63 Tablet Refills: *0 8. Enoxaparin Sodium 40 mg SC Q 24H RX *enoxaparin 40 mg/0.4 mL ___aily Disp #*42 Syringe Refills: *0 9. Fluticasone Propionate 110mcg 2 PUFF IH BID <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> repeat cesarean section for Nonreactive NST asthma exacerbation h/o DVT on lovenox for 6 week postpartum <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> See ob sheet Keep all appointments including pulmonology
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___ yo G4P1 at 36w5d with severe asthma, hx chronic pain and oxycodone use, DVT in ___ on anticoagulation presents now with acute asthma exacerbation. Patient improved with duonebs and sats remained above 92%. Was seen by medicine who recommended albuterol neb q4h, Flovent 220mcg bid, 60 mg IV methylprednisone q8h, Azithro, Singulair. Had a negative CXR and negative flu swab. Was also seen by pulmonology. Regarding her history of DVT, she had an echo: Nml regional and global biventricular systolic function. Nml diastolic function. No pathologic valvular abnml. No evid of acute right ventricular strain or dilation; as well as Negative ___. Given near-term gestational age, was transitioned to SQ UFH 7500mg BID. She remained stable on the floor. On ___, the patient's fetal heart tracing showed minimal variability at one point, and she was further evaluated with a BPP and it showed ___. On the evening of ___, the patient had repeat testing fetal heart tracing, and it showed no accelerations. Her repeated BPP showed ___, -2 for breathing, and -2 for fetal movements. The patient was then brought to labor and delivery for continuous monitoring. The fetal heart tracing continued to show intermittent minimal variability and occasional moderate variability; however, there was no accelerations. In addition, the patient had reported decreased fetal movement. After an extensive discussion with the patient, the decision was made to proceed with repeat C-section for nonreassuring fetal heart tracing. Findings included a male infant, weight 2200 g (small for gestational age), with a nuchal cord x1 and mild meconium-stained amniotic fluid. Post-operatively, the patient did well. She was followed by pulmonology and was trasitioned from IV methylprednisone to PO predinisone 40mg daily and discharged on a prednisone taper. She was transitioned from standing q4hours albuterol nebulizer treatments to PRN to albuterol MDI. Patient completed a 5 day course of azithromycin. Patient discharged home in stable condition on POD 4, with instructions to follow up with pulmonology in 2 weeks.
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11027433-DS-19
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___ <CHIEF COMPLAINT> undesired pregnancy <MAJOR SURGICAL OR INVASIVE PROCEDURE> D&E, ___ IUD insertion <HISTORY OF PRESENT ILLNESS> ___ G6 ___ @ approx. 17w by uncertain LMP presents to the Family Planning Clinic with acute situational anxiety to pregnancy, desiring pregnancy termination. She is unequivocal in her desire for termination. Her last depo injection was ___, and she missed her following ___ appt. She has been sexually active with one ___ in the interim and believes she got pregnant ___. She took a home UPT 3wks ago which was positive, confirmed by PCP 2wks ago. She reports that she has made this decision to terminate by herself. She reports that this is just not the right time for her to be pregnant both culturally and financially. She spoke with social work today. She has been able to speak openly with her best friend and sister, and believes she has their support. FOB knows and is supportive though no longer in a relationship. <PAST MEDICAL HISTORY> - Asthma: Diagnosed at age ___ requiring one intubation and then quiescent from age ___ until ___. - Juvenile arthritis first diagnosed at ___ years old. treated with embrel, prednisone x ___ years, MTX. Most recently she was on MTX and naprosyn but d/c'ed these when she was pregnant. - Pericarditis at age ___, related to the arthritis - R shoulder OA and torn rotator cough requiring surgical repair - s/p b/l hip replacement at age ___ - S/p R shoulder athroscopy - s/p hernia repair at 18 months - DVT left leg dx ___ PSH: - B/L hip replacement - Hernia repair as a child - Open appendectomy - Right shoulder arthroscopy <SOCIAL HISTORY> ___ <FAMILY HISTORY> cousin with severe asthma, MGF with lung cancer in his ___ <PHYSICAL EXAM> General: NAD, comfortable CV: RRR Lungs: CTAB Abdomen: soft, non-distended, fundus firm, non-tender at the level of the umbilicus GU: pad with moderate spotting Extremities: no edema, no TTP, pneumoboots in place bilaterally <PERTINENT RESULTS> ___ 02: 30PM BLOOD WBC: 10.5* RBC: 4.05 Hgb: 11.3 Hct: 34.2 MCV: 84 MCH: 27.9 MCHC: 33.0 RDW: 13.1 RDWSD: 40.___ ___ 02: 30PM BLOOD Plt Ct: 245 <MEDICATIONS ON ADMISSION> Naprosyn <DISCHARGE MEDICATIONS> 1. Acetaminophen ___ mg PO Q6H: PRN Pain - Mild/Fever NOT relieved by Ibuprofen 2. Enoxaparin Sodium 40 mg SC Q24H 3. Ferrous Sulfate 325 mg PO BID Duration: 1 Month Do not take with an empty stomach. Please take with orange juice or lemonade. RX *ferrous sulfate 325 mg (65 mg iron) 1 tablet(s) by mouth two times a day Disp #*60 Tablet Refills: *1 4. Ibuprofen 600 mg PO Q6H: PRN Pain - Mild/Fever <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> Acute situation anxiety of pregnancy <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Dear Ms. ___, You were admitted to the gynecology service after your procedure. You have recovered well and the team believes you are ready to be discharged home. Please call ___ office with any questions or concerns. Please follow the instructions below. General instructions: * Take your medications as prescribed. * Take a stool softener such as Konsyl while taking opioids to prevent constipation. * Do not take more than 4000mg acetaminophen (APAP) in 24 hrs. * No strenuous activity until your post-op appointment. * You may eat a regular diet. * You may walk up and down stairs. 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 US guided D&E and Liletta placement, complicated by difficult intubation and hemorrhage. Please see the operative report for full details. Her post-operative course was uncomplicated. Immediately post-op, her pain was controlled with oral ibuprofen and acetaminophen, with chlorosept/cepacol for sore throat. On post-operative day 1, she voided spontaneously with adequate urine output. Her diet was advanced without difficulty, and her pain continued to be well tolerated on oral ibuprofen and acetaminophen. By post-operative day 1, she was tolerating a regular diet, voiding spontaneously, ambulating independently, and pain was controlled with oral medications. She was then discharged home in stable condition with outpatient follow-up scheduled.
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11031209-DS-16
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> hydrocodone / shellfish derived <ATTENDING> ___. <CHIEF COMPLAINT> syncope, large pelvic hematoma <MAJOR SURGICAL OR INVASIVE PROCEDURE> Diagnostic laparoscopy, evacuation of pelvic hematoma, right salpingo-oophorectomy. <HISTORY OF PRESENT ILLNESS> Pt is a ___ y/o who is s/p egg retrieval on ___ of 29 eggs after Lupron trigger. She presented to an OSH ED for syncope and was found to have systolic BPs in the ___ which then responded to IVF. She had a CT scan which showed large pelvic hematoma <PAST MEDICAL HISTORY> PMHx denies h/o asthma, HTN, CAD PSHx: LTCS + LSC appy, tonsillectomy POBHx: G1P1 - LTCS x 1 <PHYSICAL EXAM> Discharge physical exam Vitals: VSS Gen: NAD, A&O x 3 CV: RRR Resp: no acute respiratory distress Abd: soft, appropriately tender, no rebound/guarding, incision c/d/i Ext: no TTP <PERTINENT RESULTS> LABS: ==== ___ 08: 49PM LACTATE-2.3* ___ 08: 40PM GLUCOSE-154* UREA N-12 CREAT-0.7 SODIUM-138 POTASSIUM-4.8 CHLORIDE-104 TOTAL CO2-18* ANION GAP-21* ___ 08: 40PM estGFR-Using this ___ 08: 40PM ALT(SGPT)-18 AST(SGOT)-15 ALK PHOS-42 TOT BILI-0.2 ___ 08: 40PM LIPASE-16 ___ 08: 40PM ALBUMIN-3.1* CALCIUM-7.8* PHOSPHATE-1.8* MAGNESIUM-1.7 ___ 08: 40PM HCG-<5 ___ 08: 40PM WBC-16.4* RBC-3.47* HGB-9.2* HCT-29.0* MCV-84 MCH-26.5 MCHC-31.7* RDW-14.0 RDWSD-42.6 ___ 08: 40PM NEUTS-91.0* LYMPHS-5.1* MONOS-2.8* EOS-0.1* BASOS-0.3 IM ___ AbsNeut-14.89* AbsLymp-0.83* AbsMono-0.46 AbsEos-0.01* AbsBaso-0.05 ___ 08: 40PM PLT COUNT-214 ___ 08: 40PM ___ PTT-23.9* ___ <MEDICATIONS ON ADMISSION> ASA 81mg QD Follistim <DISCHARGE MEDICATIONS> 1. Acetaminophen ___ mg PO Q6H: PRN Pain - Mild Do not take more than 4000mg in 24 hours RX *acetaminophen 500 mg ___ tablet(s) by mouth every 6 hours Disp #*50 Tablet Refills: *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. OxyCODONE (Immediate Release) ___ mg PO Q4H: PRN Pain - Moderate ___ cause sedation. Do not take with alcohol or while driving RX *oxycodone 5 mg ___ tablet(s) by mouth every 4 hours Disp #*25 Tablet Refills: *0 <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> pelvic hematoma acute blood loss anemia requiring 2 units blood tfrrasnfusion <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. * You may eat a regular diet. * You may walk up and down stairs. Incision care: * You may shower and allow soapy water to run over incision; no scrubbing of incision. No tub baths for 6 weeks. * If you have steri-strips, leave them on. They will fall off on their own or be removed during your followup visit. Call your doctor for: * fever > 100.4F * severe abdominal pain * difficulty urinating * vaginal bleeding requiring >1 pad/hr * abnormal vaginal discharge * redness or drainage from incision * nausea/vomiting where you are unable to keep down fluids/food or your medication To reach medical records to get the records from this hospitalization sent to your doctor at home, call ___.
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On ___, Ms. ___ was admitted to the gynecology service after undergoing diagnostic laparoscopy and right salpingo-oophorectomy with evacuation of hemoperitoneum due to persistent bleeding from right ovary. She received two units of pRBCs intraoperatively. 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 acetaminophen. On post-operative day 1, her urine output was adequate so her foley was removed and she voided spontaneously. Her diet was advanced without difficulty and she was transitioned to PO oxycodone and acetaminophen. NSAIDs were held. Her hct was trended to be stable at 29.0 pre-operatively and improved to 31.0 on POD1. By post-operative day 1, she was tolerating a regular diet, voiding spontaneously, ambulating independently, and pain was controlled with oral medications. She was then discharged home in stable condition with outpatient ___ scheduled.
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11033005-DS-6
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> morphine / codeine / Vicodin / Roxicet <ATTENDING> ___ <CHIEF COMPLAINT> symptomatic fibroid uterus <MAJOR SURGICAL OR INVASIVE PROCEDURE> Total Laparoscopic Hysterectomy-Bilateral Salpingectomy, excision endometriosis, extensive Lysis Of Adhesions, cystoscopy <HISTORY OF PRESENT ILLNESS> ___ G0 P0 ___ AAF w/ depression, anxiety, obesity (s/p xlap ML vert gastric bypass + chole ___, h/o genital herpes, iron deficiency anemia, and recurrent uterine fibroids (s/p xlap LT ABD MMY + panniculectomy ___ --> undergoing ___ GYN opinion regarding min inv approach for fibroid surgery, requesting TLH. Patient is scheduled to undergo TLH BS for definitive surgical treatment of her fibroid uterus, predominantly masking with/compression symptoms (pelvic pressure, urinary frequency). Patient was started on Lupron to decrease her overall uterine/fibroid size to diminish her uterine/fibroid morcellation requirements and to optimize a minimally invasive approach. Patient reports transient menopausal symptoms of insomnia and has occasional hot flashes. Her insomnia lasted 5 days but is now improved. She is tolerating to Lupron well overall. <PAST MEDICAL HISTORY> OBSTETRIC HISTORY: G0 P0 GYNECOLOGIC HISTORY: - Menarche age ___, LMP ___ -On COCs since her ___ for debilitating mittelschmerz pain. On and off COCs, she reports regular menses at 1 month intervals without menorrhagia. On COCs, regular menses every 28 days ___ days of moderate flow, unchanged baseline dysmenorrhea which is well-tolerated, significant improvement of midcycle pain/mittelschmerz. - Last PAP ( ___: Reportedly negative. Denies history of abnormal Pap. - Last mammogram ___ reportedly negative. - Pt is not currently sexually active, heterosexual. - Contraception: Tri-Sprintec COCs for medical treatment of mittelschmerz pain. - STD History: Genital herpes MEDICAL PROBLEMS: 1. Obesity, status post open gastric bypass surgery with concomitant cholecystectomy in ___. Starting weight was 330 pounds, largest weight 240 pounds, current weight 303 pounds. 2. Depression, anxiety, well managed medically 3. Iron deficiency anemia, believed to be secondary to malabsorption status post gastric bypass. 4. Recurrent uterine fibroids, status post prior abdominal myomectomy with concomitant panniculectomy ___. 5. History of genital herpes SURGICAL HISTORY: 1. ___, xlap midline vertical incision, open gastric bypass + cholecystectomy 2. ___, xlap low transverse incision, abdominal myomectomy + panniculectomy 3. ___, wisdom tooth extraction <SOCIAL HISTORY> ___ <FAMILY HISTORY> - Denies family h/o gynecologic cancers. -Reports a family history notable for father with diabetes, hypertension, heart disease, hypercholesteremia - Maternal uncle with brain cancer <PHYSICAL EXAM> Vitals: VSS Gen: NAD, A&O x 3 CV: RRR Resp: no acute respiratory distress Abd: soft, appropriately tender, no rebound/guarding, incision c/d/i Ext: no TTP <PERTINENT RESULTS> ___ 05: 52AM BLOOD WBC-15.9*# RBC-3.94 Hgb-10.6* Hct-33.0* MCV-84 MCH-26.9 MCHC-32.1 RDW-13.9 RDWSD-42.8 Plt ___ ___ 05: 52AM BLOOD Plt ___ <MEDICATIONS ON ADMISSION> Vitamin D, Sertraline 50 mg qd, Lorazepam ___ mg qd, OrthoTri-Sprintec, lupron <DISCHARGE MEDICATIONS> 1. Acetaminophen ___ mg PO Q6H: PRN pain Do not take more than 4g per day RX *acetaminophen 500 mg ___ tablet(s) by mouth every 6 hours Disp #*30 Tablet Refills: *0 2. HYDROmorphone (Dilaudid) ___ mg PO Q4H: PRN pain Do not drive while taking med RX *hydromorphone 2 mg 1 tablet(s) by mouth every 4 hours Disp #*30 Tablet Refills: *0 3. Ibuprofen 600 mg PO Q6H: PRN Pain Take with food RX *ibuprofen 600 mg 1 tablet(s) by mouth every 6 hours Disp #*30 Tablet Refills: *0 4. Sertraline 50 mg PO DAILY 5. Docusate Sodium 100 mg PO BID RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice a day Disp #*30 Capsule Refills: *2 <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> symptomatic fibroid uterus <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> 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. ___ had a ___, excision endo, extensive LOA, cysto for symptomatic fibroid uterus. She was admitted to the gynecology service for observation because it was a long and challenging surgery; however, there were no intra-op issues. Please see the operative report for full details. Her post-operative course was uncomplicated. Immediately post-op, her pain was controlled with IV pain medications. On post-operative day 1, her urine output was adequate so her foley was removed and she voided spontaneously. Her diet was advanced without difficulty and she was transitioned to oral pain meds. 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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11035119-DS-3
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Dilaudid / Ciprofloxacin / Prochlorperazine / Latex / Shellfish / Lactose <ATTENDING> ___. <CHIEF COMPLAINT> 39 and ___ weeks GA, on heparin for hx PE, GDMA2 and now separated pubic symphysis <MAJOR SURGICAL OR INVASIVE PROCEDURE> normal vaginal delivery <HISTORY OF PRESENT ILLNESS> ___ yr G1Po ___ ___ now at 39 and ___ weeks for IOL for multiple issues. Pt currently on heparin 5,000 subQ BID for hx bilateral pulmonary emboli while on OCP's. Pt also with GDMA2 which ahs been well controlled on insulin adntakes between 12 and 18 units pre-meals aand qhs. Pt now with separated symphysis since ___ weeks for which she walks on crutches and takes oxy-codone prn. Due to these multiple issues IOL warranted at 39 weeks completed GA. Pt did have amnio for FLM one week ago at 38 weeks but was borderline at 43 so IOL delayed until 39 weeks GA. ___ reports had PTc's since ___ weeks and now rare ctx's. No rom, no bleeding, active FM. serial antenatal testing for GDMA2 all reasurring and last EFW on ___ was 2698gms (5#15ounces) in 40% with normal AC. <PAST MEDICAL HISTORY> A+, abneg, RPR NR, hebsAg, CF neg, GBS neg nl survey, normal ERA and AFP GDMA2--followed by ___ since ___ weeks hx palpitations and dizziness during pregnancy--saw cardiology/ holter neg except for pvc's/ echo normal/ felt vaso-vagal in origin and no further cardiac w/u needed -on lovenox and now e heprarin sicne 36 weeks for hx PE PMH 1. ___- bilateral PE's while on OCp's / w/u negative for hypercoagulable state-- was rx'd with coumadin and now on heparin. followed by hematologist at ___ 2. hx PCOS 3. hx ___ worried re PPD--rec SW consult post-partum..has psych that follow and remains on celexa 4.hypothyroidism--followed by endocrine--TFT's well controlled throughout pregnancy PSH -varicose vein stripping ___ tendon repair <SOCIAL HISTORY> ___ <FAMILY HISTORY> noncontributory <PHYSICAL EXAM> (on admission) ___ FHR reactive chest-cta card-rrr lungs-CTA abdomen-- sift, nt, nd S=D vertex ext-NT 1+ ___ edema VE 2.5/thick/-posterior/-2 station GBS neg <PERTINENT RESULTS> ___ 10: 30PM BLOOD WBC-11.6* RBC-4.10* Hgb-12.0 Hct-36.0 MCV-88 MCH-29.3 MCHC-33.4 RDW-13.9 Plt ___ ___ 10: 30PM BLOOD ___ PTT-24.9 ___ ___ 10: 30PM BLOOD ___ ___ 06: 15AM BLOOD Creat-0.5 ___ Pelvic X-ray "SI joint and pubic symphysis diastasis. No fracture detected." <MEDICATIONS ON ADMISSION> oxycodone pprn heparin per patient takes 5,000 units subq BID / ? per Dr. ___ notes on 10,000 subQ BID. insulin--per ___ 12- 18 units pre-meals and NPH qhs LEVOXYL CELEXA PNV'S <DISCHARGE MEDICATIONS> 1. levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for Constipation. 4. Acetaminophen Extra Strength 500 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for Pain. 5. enoxaparin 100 mg/mL Syringe Sig: One (1) Subcutaneous once a day. Disp: *30 * Refills: *1* 6. breast pump Sig: One (1) every four (4) hours: hospital grade. poor latch. infant separation . Disp: *1 * Refills: *0* <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> term pregnancy delivered symphysis pubis separation gestational diabetes <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> see discharge sheet
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On ___, Ms. ___ was admitted for induction of labor for her medical comorbidities. Her coagulation labs were within normal limits. On ___, she delivered a male infant (apgars 7 and 8). Please refer to delivery note for details. Postpartum, she was followed by ___ for her GDMA2, and her fasting and postprandial fingerstick glucoses levels over 48 hours postpartum were acceptable. She was on lovenox 40mg for 48 hours postpartum, and ___, she was increased to lovenox ___ daily, which she will continue for 6 weeks. She continued to take oxycodone for pelvic pain, and an x-ray pelvis on ___ showed SI joint and pubic symphysis diastasis. As part part of her home safety evaluation, she had two sessions with physical therapy, who recommended home physical therapy. She was also seen by social work for her history of depression and oxycodone use in pregnancy.
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11036328-DS-17
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> lisinopril <ATTENDING> ___ <CHIEF COMPLAINT> endometrial intraepithelial neoplasia <MAJOR SURGICAL OR INVASIVE PROCEDURE> planned total laparoscopic hysterectomy --> converted to laparoscopic supracervical hysterectomy, bilateral salpingectomies, extensive lysis of adhesions, and cystoscopy <PHYSICAL EXAM> Discharge physical exam Vitals: VSS Gen: NAD, A&O x 3 CV: RRR Resp: no acute respiratory distress Abd: soft, appropriately tender, no rebound/guarding, incision c/d/i Ext: no TTP <MEDICATIONS ON ADMISSION> nifedipine 90mg daily <DISCHARGE MEDICATIONS> 1. Acetaminophen ___ mg PO Q6H: PRN Pain - Mild Do not exceed 4,000mg in 24 hours. RX *acetaminophen 500 mg ___ tablet(s) by mouth every 6 hours Disp #*50 Tablet Refills: *1 2. Docusate Sodium 100 mg PO BID RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice daily Disp #*60 Capsule Refills: *0 3. Ibuprofen 400 mg PO Q8H: PRN Pain - Moderate Take with food or milk. RX *ibuprofen 400 mg 1 tablet(s) by mouth every 6 hours Disp #*50 Tablet Refills: *1 4. Nitrofurantoin (Macrodantin) 100 mg PO BID Duration: 5 Days Please take the full course of this medication. RX *nitrofurantoin macrocrystal 100 mg 1 capsule(s) by mouth twice daily Disp #*9 Capsule Refills: *0 5. Omeprazole 20 mg PO DAILY RX *omeprazole 20 mg 1 capsule(s) by mouth daily Disp #*30 Capsule Refills: *2 6. OxyCODONE (Immediate Release) 5 mg PO Q4H: PRN Pain - Severe Do not drink alcohol or drive. RX *oxycodone 5 mg 1 tablet(s) by mouth every 4 hours Disp #*20 Tablet Refills: *0 <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 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. Urinary Tract Infection (UTI): * You were found to have a UTI during your admission. * Take the full course of your antibiotics, even if you start to feel better. General instructions: * Take your medications as prescribed. * Do not drive while taking narcotics. * Take a stool softener such as colace while taking narcotics to prevent constipation. * Do not combine narcotic and sedative medications or alcohol. * Do not take more than 4000mg acetaminophen (APAP) in 24 hrs. * No strenuous activity until your post-op appointment. * Nothing in the vagina (no tampons, no douching, no sex) for 3 months. * No heavy lifting of objects >10 lbs for 6 weeks. * You may eat a regular diet. * You may walk up and down stairs. Incision care: * You may shower and allow soapy water to run over incision; no scrubbing of incision. No tub baths for 6 weeks. * If you have steri-strips, leave them on. They will fall off on their own or be removed during your followup visit. Call your doctor for: * fever > 100.4F * severe abdominal pain * difficulty urinating * vaginal bleeding requiring >1 pad/hr * abnormal vaginal discharge * redness or drainage from incision * nausea/vomiting where you are unable to keep down fluids/food or your medication To reach medical records to get the records from this hospitalization sent to your doctor at home, call ___.
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On ___, Ms. ___ was admitted to the gynecology service after undergoing laparoscopic supracervical hysterectomy, bilateral salpingectomies, extensive lysis of adhesions, and cystoscopy. Please see the operative report for full details. Her post-operative course was uncomplicated. Immediately post-op, her pain was controlled with IV dilaudid. On post-operative day 1, her urine output was adequate so her foley was removed and she voided spontaneously. She endorsed dysuria, so a UA was sent which was positive for infection, with urine culture pending She was started on Nitrofurantoin (antibiotics) for a total of 5 day course. Her diet was advanced without difficulty and she was transitioned to oxycodone, acetaminophen, ibuprofen (pain meds). 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. ADDENDUM: final Ucx came back neg
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11038341-DS-19
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Patient recorded as having No Known Allergies to Drugs <ATTENDING> ___. <CHIEF COMPLAINT> Abdominal pain <MAJOR SURGICAL OR INVASIVE PROCEDURE> Exploratory laparotomy, pelvic washings, extensive pelvic adhesiolysis, left salpingo-oophorectomy, total abdominal hysterectomy, right salpingo-oophorectomy, ileocolectomy <HISTORY OF PRESENT ILLNESS> ___ yo ___ presented to the ED with complaints of lower abd pain. Pain started one week ago, localized to her uterus. Pain is described as crampy, occasionally sharp. Does not radiate. Over the past week, noted increased pain with urination, bowel movements, intercourse, and change in position and she came into the ED. No recent changes in weight. Has noted decreased appetite over the past week. No early satiety. No increase in abdominal girth, however she did note a 'bulge' in the LLQ in the shower this morning. No f/c. No n/v. No CP. Occasional SOB due to her asthma. No dysuria, frequency, or hematuria. No constipation or diarrhea. Pt has received Morphine and Zofran in the ED with improvement in pain. Also received one dose of Levaquin. <PAST MEDICAL HISTORY> OBHx: SVD x 3, TAB x 2 GynHx: LMP ___. Regular menses q month. Last pap ___. No h/o abnormal paps per pt. No h/o STDs, reports having a vaginal infection a few years ago. Uterine fibroids on prior U/S. Pt with prior pelvic U/S in ___ and ___ which showed uterine fibroids, largest 1-2 cm and normal ovaries bilaterally. Sexually active with one male partner. Last mammogram ___, no recent mammogram. PMH: Reactive airway disease. ___ spirometry showed moderate-->severe obstructive ventilatory defect. No h/o colonoscopy. PSH: None <SOCIAL HISTORY> ___ <FAMILY HISTORY> Mother deceased age ___ due to lung cancer. Father deceased age ___, had T2DM. No family h/o breast CA, gyn CA, colon CA. <PHYSICAL EXAM> -1835: T 97.6, HR 136, BP 110/65, RR 18, 98%RA -___: T 97.8, HR 97, BP 99/79, RR 15, 98% RA -0110: T 98.9, HR 105, BP 129/93, RR 17, 97% RA Appears comfortable at rest, mild discomfort when attempts to sit Lungs: Coarse breath sounds bilaterally with faint expiratory wheezes CV: Tachycardic. No murmurs Abd: Soft, mild distended, mass palpated in lower abdomen below umbilicus. Mild tenderness to palpation diffusely in lower abdomen LLQ>RLQ. No rebound/guarding. Ext: No ___, NT SVE: Cervix palpated. Pt with tenderness in lower pelvis during vaginal exam. Enlarged full mass palpated, exact borders difficult to determine, tenderness of LLQ. <PERTINENT RESULTS> ___ 06: 52PM BLOOD WBC-12.9*# RBC-3.99* Hgb-9.3* Hct-28.9* MCV-73*# MCH-23.2*# MCHC-32.1 RDW-15.8* Plt ___ ___ 09: 00PM BLOOD WBC-15.6* RBC-3.77* Hgb-9.8*# Hct-28.8* MCV-76* MCH-25.9*# MCHC-33.9 RDW-15.6* Plt ___ ___ 06: 10AM BLOOD WBC-21.9* RBC-3.88* Hgb-10.0* Hct-29.8* MCV-77* MCH-25.7* MCHC-33.4 RDW-15.7* Plt ___ ___: 15AM BLOOD WBC-14.1* RBC-3.80* Hgb-9.6* Hct-29.7* MCV-78* MCH-25.4* MCHC-32.5 RDW-16.1* Plt ___ ___ 06: 52PM BLOOD Neuts-74.7* Lymphs-14.7* Monos-9.5 Eos-0.4 Baso-0.7 . ___ 06: 52PM BLOOD ___ PTT-28.9 ___ . ___ 06: 52PM BLOOD Glucose-123* UreaN-14 Creat-1.0 Na-133 K-3.6 Cl-94* HCO3-26 AnGap-17 ___ 06: 10AM BLOOD Glucose-142* UreaN-9 Creat-0.7 Na-134 K-3.9 Cl-97 HCO3-30 AnGap-11 ___ 06: 15AM BLOOD Glucose-91 UreaN-7 Creat-0.6 Na-136 K-3.9 Cl-102 HCO3-29 AnGap-9 . ___ 06: 52PM BLOOD ALT-10 AST-14 AlkPhos-78 TotBili-0.5 ___ 05: 25AM BLOOD Calcium-8.2* Phos-2.8 Mg-1.8 ___ 06: 05AM BLOOD Calcium-8.2* Phos-2.7 Mg-2.1 ___ 06: 15AM BLOOD Calcium-7.7* Phos-2.7 Mg-1.9 . ___ 07: 30PM BLOOD CA125-43* ___ 09: 00PM BLOOD CEA-2.8 . ****Labs at time of discharge*** . CT abd/pelvis ___ IMPRESSION: 1. 14 x 8 x 8 cm multiseptated cystic mass within the pelvis, likely arising from the left ovary, is concerning for an ovarian neoplasm including cystadenocarcinoma or, less likely, cystadenoma. A peritoneal inclusion cyst is considered less likely as a normal left ovary is not seen. Pelvic ultrasound and MRI is recommended for further characterization. 2. Two hypoattenuating ill-defined hepatic lesions are concerning for metastatic disease, given the presence of the pelvic mass, but are incompletely characterized on single phase study. Liver MRI is recommended for further evaluation. 3. No evidence of diverticulitis or appendicitis. 4. Cholelithiasis without cholecystitis. 5. Mild bilateral hydronephrosis. 6. Emphysema identified at the lung bases. . CXR ___ IMPRESSION: No acute cardiopulmonary abnormality . PELVIC U/S ___ IMPRESSION: Large, complex cystic mass in the pelvis with thickened septations demonstrating increased flow. Findings are concerning for cystadenocarcinoma or cystadenoma. . PATHOLOGY Moderately differentiated adenocarcinoma involving ovary, consistent with metastasis from cecal primary. <MEDICATIONS ON ADMISSION> Albuterol, Flovent <DISCHARGE MEDICATIONS> 1. Albuterol 90 mcg/Actuation Aerosol Sig: ___ Puffs Inhalation Q4H (every 4 hours) as needed. 2. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation BID (2 times a day). 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp: *60 Capsule(s)* Refills: *2* 4. Oxycodone-Acetaminophen ___ mg Tablet Sig: ___ Tablets PO Q4H (every 4 hours) as needed. Disp: *50 Tablet(s)* Refills: *0* 5. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed. Disp: *50 Tablet(s)* Refills: *0* <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> Metastatic colon cancer <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 ___ woman who presented to the ED with abdominal pain. She had a CT abdomen/pelvis and pelvic ultrasound that revealed a 16 x 11 x 12 cm mass that was thought to be ovarian in origin. She was also noted to have anemia, with a hct of 28. In the ED, she had an EKG, which was significant for T wave changes in the anterior leads. (She was maintained on telemetry until 3 negative sets of cardiac enzymes were obtained.) She was admitted to the gyn oncology service. On HD#1, a medicine consult was obtained for surgical clearance. As she does have a history of reactive airway disease, albuterol nebulizer treatments, flovent, and respiratory physiotherapy were recommended. A preoperative chest xray showed no evidence of acute disease. CA125 was 43 and CEA (obtained postoperatively) was 2.3. On HD#2, she underwent exploratory laparotomy, pelvic washings, extensive pelvic adhesiolysis, left salpingo-oophorectomy, total abdominal hysterectomy, right salpingo-oophorectomy, and ileocolectomy. Intraoperatively, the primary tumor was felt to be arising from the cecum and general surgery performed the bowel resection and reanastamosis. She was transfused 2u pRBCs during the procedure. Please see full operative note for details. Her postoperative course was complicated by the following issues: *) Ileus: On POD#1, the pt's diet was advanced, but she had an episode of emesis on POD#2. She never had significant nausea, but she was placed NPO on maintenance IV fluids. Electrolytes were checked daily and repleted prn. She finally passed flatus on POD#6 and her diet was advanced slowly until she was able to tolerate a regular diet. . *) Anemia: Likely iron deficiency anemia secondary to blood loss related to lower GI bleed from colon cancer. Her hematocrit responded appropriately to blood transfusion and remained stable from ___ throughout her admission. . *) Pulmonary: Her lung disease was not an issue during her hospitalization. She received albuterol prn. . *) Thrombocytosis: Patient's platelet count slowly increased during her hospitalization, likely a reactive thrombocytosis. After discussion with hemotology, no treatment was recommended. Platelet count at time of discharge was 1053 K/uL. Patient will follow up with her primary care physician. . The pathology report was finalized prior to discharge and found to be consistent with primary colon cancer with metastases to the ovary. She was discharged home on POD#8 in stable condition.
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11038628-DS-14
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Sulfa (Sulfonamide Antibiotics) <ATTENDING> ___. <CHIEF COMPLAINT> Poor fetal growth on ultrasound, low fluid, hypertension <MAJOR SURGICAL OR INVASIVE PROCEDURE> D&E <HISTORY OF PRESENT ILLNESS> Hypertension, followed as an outpatient, poor fetal growth. <PAST MEDICAL HISTORY> PMH: HTN, PCOS, hypercholesterol, MO, depression, hypothyroid <SOCIAL HISTORY> ___ <FAMILY HISTORY> Multiple family members w/ gallstone disease <PHYSICAL EXAM> 130s-140s/70s-80s Afebrile Abd soft Ext benign <PERTINENT RESULTS> ___ 01: 00PM CREAT-0.5 ___ 01: 00PM estGFR-Using this ___ 01: 00PM ALT(SGPT)-14 ___ 01: 00PM URIC ACID-5.4 ___ 01: 00PM URINE HOURS-RANDOM CREAT-30 TOT PROT-<6 ___ 01: 00PM WBC-15.3*# RBC-3.94* HGB-12.0 HCT-34.0* MCV-86 MCH-30.5 MCHC-35.3* RDW-14.3 ___ 01: 00PM PLT COUNT-314 ___ 01: 00PM URINE COLOR-Straw APPEAR-Clear SP ___ ___ 01: 00PM URINE BLOOD-MOD NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-MOD ___ 01: 00PM URINE RBC-1 WBC-4 BACTERIA-FEW YEAST-NONE EPI-2 TRANS EPI-<1 <MEDICATIONS ON ADMISSION> Levoxyl, prozac <DISCHARGE MEDICATIONS> 1. Doxycycline Hyclate 200 mg PO 1X Duration: 1 Doses RX *doxycycline hyclate 100 mg 1 capsule(s) by mouth twice a day Disp #*8 Capsule Refills: *0 2. Fluoxetine 20 mg PO DAILY 3. Ibuprofen 600 mg PO Q6H: PRN pain 4. Levothyroxine Sodium 75 mcg PO DAILY 5. Oxazepam 15 mg PO HS: PRN insomnia RX *oxazepam 15 mg 1 capsule(s) by mouth at bedtime Disp #*20 Capsule Refills: *0 <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> Pre-eclampsia, abruption <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> No exercise for one week. No heavy lifting for ___ days. Nothing in vagina for two weeks. No restrictions on bathing, showering, other activities.
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Patient admitted with hypertension, poor fetal growth. Developed vaginal bleeding, placental abruption, underwent D&E. Uncomplicated post-op course.
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11044044-DS-3
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> acetaminophen <ATTENDING> ___. <CHIEF COMPLAINT> Fever, vulvar pain <MAJOR SURGICAL OR INVASIVE PROCEDURE> None <HISTORY OF PRESENT ILLNESS> Ms ___ is an ___ G0 transferred from ___ for PID failing outpt therapy. ___ noted "vaginal pain" on ___, presdented to her PCP and had STI testing. Her symptoms worsened over the next 2 days and chlamydia returned positive on ___ AM. She was prescriped a PO regimen for G&C (zithromax and uncertain other medication)and was unable to tolerate, vomiting all medications shortly after taking. She began to feel poorly at home, with subjective fevers and chills. Her vulvar pain worsened over the course of the day to the point she presented to ___. There, she was febrile to 101.6 and tachy to 150-160s. No pelvic exam was performed due to her extreme sensitivity despite dilaudid, but PID was presumed. She was given IVF, tylenol, IV cefoxitin, flagyl and doxy, and po acyclovir. Serum HCG negative. A pelvic US did not note ovarian mass to suggest ___. WBC 9.4. C&G cultures were obtained by blindly swabbing posterior fornix. She was transferred to ___ for gyn evaluation. <PAST MEDICAL HISTORY> PGynHx: Menarche age ___, regular periods q 5 month x ___ days Denies dysmenorrhea, menorrhagia, fibroids, cysts. Hx of chlamydia age ___ s/p tx. 3 lifetime sexual partners. Has used ___ since ___ q 3 months, last dose ___ PMhx: denies PSHx: denies <SOCIAL HISTORY> ___ <FAMILY HISTORY> Noncontributory <PHYSICAL EXAM> Physical Exam on Discharge: VSS CV: RRR Pulm: CTAB Abd: soft nontender, nondistended, +BS GU: lesions consistent with HSV across both labia Ext: warm well perfused, nontender to palpation <PERTINENT RESULTS> ___ 08: 45AM BLOOD WBC-7.3 RBC-3.75* Hgb-11.0* Hct-33.1* MCV-88 MCH-29.3 MCHC-33.3 RDW-13.2 Plt ___ ___ 08: 45AM BLOOD Neuts-74.2* Lymphs-16.6* Monos-8.6 Eos-0.4 Baso-0.2 ___ 08: 45AM BLOOD CRP-73.1* ___ 08: 45AM BLOOD ESR-29* URINE CULTURE (Final ___: NO GROWTH. RAPID PLASMA REAGIN TEST (Final ___: NONREACTIVE. Reference Range: Non-Reactive. VIRAL CULTURE: R/O HERPES SIMPLEX VIRUS (Final ___: HERPES SIMPLEX VIRUS TYPE 1. Viral antigen identified by immunofluorescence. <MEDICATIONS ON ADMISSION> The Preadmission Medication list is accurate and complete. 1. This patient is not taking any preadmission medications <DISCHARGE MEDICATIONS> 1. Acyclovir 400 mg PO Q8H RX *acyclovir 400 mg 1 tablet(s) by mouth every eight (8) hours Disp #*21 Tablet Refills: *0 2. Dibucaine 1 Appl TP QID: PRN pain RX *dibucaine 1 % apply to affected area four times a day Disp #*1 Tube Refills: *1 3. Doxycycline Hyclate 100 mg PO Q12H RX *doxycycline hyclate 100 mg 1 tablet(s) by mouth twice a day Disp #*14 Tablet Refills: *0 4. Gabapentin 200 mg PO TID pain RX *gabapentin 100 mg 2 capsule(s) by mouth three times a day Disp #*30 Capsule Refills: *0 5. Ibuprofen 600 mg PO Q6H: PRN fever, pain RX *ibuprofen 600 mg 1 tablet(s) by mouth every six (6) hours Disp #*60 Tablet Refills: *1 6. Docusate Sodium 100 mg PO BID RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day Disp #*60 Capsule Refills: *0 7. OxycoDONE (Immediate Release) ___ mg PO Q3H: PRN pain RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours Disp #*40 Tablet Refills: *0 8. Ondansetron 4 mg PO Q8H: PRN nausea RX *ondansetron 4 mg 1 tablet(s) by mouth every eight (8) hours Disp #*10 Tablet Refills: *0 <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> Primary HSV and chlamydia infection <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Dear Ms ___, You were admitted to the GYN service with pain and fever likely from primary herpes simplex virus outbreak and chlamydia infection. You were treated with IV antibiotics and acyclovir. You have recovered well and the team feels that you are ready to go home. Please follow the instructions below. General instructions: * Take your medications as prescribed. * Finish complete course of antibiotics. * Continue to use dibucaine ointment as needed for vulvar pain. * Do not drive while taking narcotics. * Take a stool softener such as colace while taking narcotics to prevent constipation * Do not combine narcotic and sedative medications or alcohol * Do not take more than 4000mg acetaminophen (APAP) in 24 hrs To reach medical records to get the records from this hospitalization sent to your doctor at home, call ___.
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Ms ___ is an ___ transferred from an OSH on ___ for vulvar pain and concern of PID for further management. Patient presented to primary care earlier in week with pelvic pain, found to have chlamydia however unable to tolerate PO medication. On admission patient noted to have primary HSV outbreak with lesions across both labia weeping serous discharge. PAtient was started on gent/clinda for 24 hours afebrile for possible PID as well as acyclovir, gabapentin and lidocaine jelly for HSV. Patient continued to have fevers on HD #1 which then resolved by HD #2. Patient recovered well with improvement in pain. Patient remained afebrile and was transitioned to doxycyline. Patient was discharged home on HD #3 with doxycycline to complete ___s well as acyclovir, gabapentin and lidocaine jelly for HSV. Patient request to follow up with primary care physician.
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11047238-DS-18
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> penicillin G / ampicillin <ATTENDING> ___ <CHIEF COMPLAINT> Rectocele <MAJOR SURGICAL OR INVASIVE PROCEDURE> Posterior Colporrhaphy, Cystoscopy, Transvaginal Sling <HISTORY OF PRESENT ILLNESS> Mrs. ___ is a ___ ___ woman who presents with multiple pelvic floor complaints. She has urinary frequency. She goes to the bathroom every 30 minutes to an hour. She also wakes up three to four times at night to urinate. This has been going on for a year at least. She has occasional urgency and denies significant urge-type incontinence. She does have stress incontinence; however, she will cough and it is especially evident during her asthmatic episodes. She also suffers from chronic constipation. Her stools are hard. She was in the emergency room four weeks ago. She says due to constipation. She also splints to defecate. She does feel a bulge and tissue protrusion in the vagina. The patient also notes that when her stools are soft that she gets fecal incontinence, that is whey she keeps them hard. She denies recurrent bladder infections, hematuria, dysuria and is not sexually active. <PAST MEDICAL HISTORY> <PAST MEDICAL HISTORY> Significant for ___, asthma, depression, acid reflux disease, cervical spondylosis. Past Surgical History: Breast cyst removed, benign. <FAMILY HISTORY> Noncontributory. Past OB History: Gravida 4, para 2, two prior vaginal deliveries, positive for forceps, negative for vacuum-assisted vaginal delivery. Past GYN History: She is in menopause since age ___. Last Pap ___ was normal. <SOCIAL HISTORY> ___ <FAMILY HISTORY> h.o HTN in the family <PHYSICAL EXAM> Upon discharge: AF, VSS Gen: NAD, A&O Pulm: no visible resp distress, speaking in full sentences Abd: soft, NT ND Ext: no c/c/e, left shoulder sling in place, unable to abduct left arm secondary to pain <PERTINENT RESULTS> HISTORY: ___ woman with history of ___ persisting left shoulder injury 1 week ago at home, unable to initiate movement in her left upper extremity. Assess for left shoulder injury. TECHNIQUE: Left shoulder 3 views: AP neutral and axillary. COMPARISON: None. FINDINGS: Nondisplaced transverse fracture of the left greater tuberosity is seen. No dislocation or periarticular erosion. No degenerative changes detected involving the glenohumeral or acromioclavicular joint. Limited view of left lung demonstrates mid lung atelectasis however this is not well evaluated. IMPRESSION: 1. Nondisplaced left greater tuberosity transverse fracture. 2. No dislocation. <MEDICATIONS ON ADMISSION> 1. Acetaminophen 500 mg PO Q6H: PRN pain 2. Carbidopa-Levodopa (___) 1 TAB PO TID 3. Carbidopa-Levodopa CR (50-200) 1 TAB PO HS 4. Fluticasone Propionate 110mcg 1 PUFF IH BID 5. Albuterol Inhaler 2 PUFF IH Q6H: PRN sob 6. Alendronate Sodium 70 mg PO Q WEEK 7. Omeprazole 20 mg PO BID <DISCHARGE MEDICATIONS> 1. Carbidopa-Levodopa (___) 1 TAB PO TID 2. Carbidopa-Levodopa CR (50-200) 1 TAB PO QHS 3. Docusate Sodium 100 mg PO BID: PRN constipation RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day Disp #*60 Capsule Refills: *1 4. Ibuprofen 400 mg PO Q6H: PRN Pain take with food, do not exceed more than 2400mg in 24 hrs RX *ibuprofen 400 mg 1 tablet(s) by mouth every 6 hrs Disp #*60 Tablet Refills: *1 5. Mirtazapine 7.5 mg PO HS 6. Omeprazole 20 mg PO DAILY 7. Oxycodone-Acetaminophen (5mg-325mg) ___ TAB PO Q4H: PRN Pain do not take >4000mg of acetaminophen/24hrs or drive while on this med RX *oxycodone-acetaminophen 5 mg-325 mg 1 tablet(s) by mouth every ___ hrs Disp #*30 Tablet Refills: *0 8. Nitrofurantoin Monohyd (MacroBID) 100 mg PO Q12H RX *nitrofurantoin monohyd/m-cryst 100 mg 1 capsule(s) by mouth twice a day Disp #*14 Capsule Refills: *0 <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> Rectocele <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Dear ___, ___ have been admitted to the Gynecology service for your scheduled operation of posterior colporrhaphy, transvaginal sling, and cystoscopy for rectocele. ___ had an uncomplicated surgery, and ___ have met all of your post operative milestones, including walking independently, tolerating a normal diet, urinating spontaneously and taking oral pain medicine for your pain. We are discharging ___ because ___ are in a good condition and ___ have a scheduled follow-up. The orthopaedics team also evaluated ___ for your left shoulder injury, please follow their recommendations and do not lift anything heavy or raise your left arm greater than 90 degrees. ___ will follow-up with orthopaedics and physical therapy as scheduled. *) ___ were discharged home with a Foley (bladder) catheter and received teaching for it prior to discharge. ___ were also given a prescription for Macrodantin (nitrofurantoin) antibiotic to prevent a UTI while ___ have the catheter. Please take as prescribed. ___ should follow-up in Dr. ___ on ___ for catheter removal. General instructions: * Take your medications as prescribed. * Do not drive while taking narcotics. * Take a stool softener such as colace while taking narcotics to prevent constipation * Do not combine narcotic and sedative medications or alcohol * Do not take more than 4000mg acetaminophen (APAP) in 24 hrs * No strenuous activity until your post-op appointment * Nothing in the vagina (no tampons, no douching, no sex) for 6 weeks * No heavy lifting of objects >10lbs for 6 weeks. * ___ may eat a regular diet Incision care: * ___ 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 ___ 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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Mrs. ___ is a ___ year old who was admitted to the Gynecology service after her scheduled posterior colporrhaphy, TVT and cystoscopy for rectocele. She had an uncomplicated procedure, please refer to the operative report for full details. She was continued on her home meds for her ___ disease. The patient failed her voiding trail on POD#1, after her foley was removed. She voided 150 cc with 800 cc retained in her bladder afer a bladder scan. The decision was made to replace the foley for bladder rest, and to follow-up with Dr. ___ in a few days. She was sent home with Macrobid for UTI prophylaxis. Of note, upon presentation prior to her surgery, the patient complained of left shoulder injury one week prior. After her surgery, the orthopaedics team evaluated her and noted a non-displaced fracture on X-Ray. They recommended limiting the use of her left arm, and to follow-up in clinic after discharge. Otherwise, the patient tolerated her operation well. She advanced her diet to regular, took oral pain medicine for pain control, and ambulated independently. She was discharged on POD#1 in good condition with good follow-up.
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11047741-DS-18
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> lisinopril <ATTENDING> ___. <CHIEF COMPLAINT> Actinomyces on endometrial biopsy <MAJOR SURGICAL OR INVASIVE PROCEDURE> None <HISTORY OF PRESENT ILLNESS> Ms. ___ is a ___ yo G8P8 who presents for direct admission given +actinomyces on EMBx. She initially presented to ___ Clinic with post-menopausal bleeding. At the time of the procedure on ___, an IUD string was seen and removed by Dr. ___. It appeared to be a Lippes Loop IUD. It was covered in tissue. An EMBx was then collected and sent for path as well as culture. In the meantime, she was placed on doxycline 100mg bid for malodorous discharge. Patient had no other complaints such as pain or fever. EMBx culture returned with actinomyces today. <PAST MEDICAL HISTORY> PAST MEDICAL & SURGICAL HISTORY: 1. Type 2 diabetes mellitus (treated with oral hypoglycemics and Lantus, however patient stopped both of these recently due to an episode of hypoglycemia) 2. Hypertension 3. Hyperlipidemia 4. Asthma (in childhood) 5. History of recurrent angioedema secondary to medications (including ACE inhibitor) 6. Coronary artery disease (s/p CABG-triple vessel ___ 7. Congestive heart failure (P-MIBI in ___ - moderate, fixed myocardial perfusion defects involving anterolateral, lateral, and inferolateral walls; global hypokinesis; EF of 34%) <SOCIAL HISTORY> Patient lives at home with by herself with the assistance of an aide and is currently unemployed; visits a senior program daily. Denies tobacco use or alcohol use; no recreational substance use. Utilizes a walker or cane for ambulation and is functional in most ADLs. <PHYSICAL EXAM> On admission: VS: 99.3 135/61 87 18 98/RA Gen: No acute distress Card: RRR no m/r/g. Resp: CTAB Abd: S/NT/ND. No masses or hepatoslenomegaly. Pelvic deferred Ext: NT/ 2+ pitting edema up to knees <PERTINENT RESULTS> ___ 01: 55PM BLOOD WBC-7.6 RBC-3.36* Hgb-9.1* Hct-30.7* MCV-91 MCH-27.2 MCHC-29.8* RDW-15.8* Plt ___ ___ 05: 15AM BLOOD Glucose-99 UreaN-34* Creat-2.0* Na-137 K-4.5 Cl-100 HCO3-27 AnGap-15 ___ 05: 38AM BLOOD Glucose-109* UreaN-28* Creat-2.1* Na-142 K-4.1 Cl-102 HCO3-29 AnGap-15 ___ 10: 50AM BLOOD UreaN-25* Creat-1.8* ___ 01: 55PM BLOOD Glucose-175* UreaN-21* Creat-1.1 Na-141 K-3.9 Cl-103 HCO3-31 AnGap-11 ___ 05: 15AM BLOOD Albumin-3.2* Iron-20* ___ 05: 15AM BLOOD calTIBC-289 VitB12-527 Folate-16.2 Ferritn-48 TRF-222 ___ 05: 15AM BLOOD PTH-115* CT Abd/Pelvis with contrast ___: : The imaged lung bases are clear. The imaged portion of the heart has severe atherosclerotic calcification. Evidence of prior CABG is noted. A few high density linear material seen along the anterior aspect of the heart may represent previously placed epicardial leads. There is no pericardial effusion. A small simple right pleural effusion is present. There is mild hypoattenuation of the liver, suggestive of mild hepatic steatosis. A hypodense lesion in segment II of the liver (2: 17) measuring 3.3 cm has attenuation values of 40 and does not meet criteria for a simple cyst. This may represent a hemangioma or a complex cyst, and ultrasound is recommended for further evaluation. There is mild diffuse thickening of both adrenal glands suggestive of adrenal hyperplasia. The spleen and the pancreas are unremarkable. Both kidneys enhance and excrete contrast symmetrically, without evidence of hydroureteronephrosis. Multiple subcentimeter hypodensities are seen in both kidneys, too small to characterize in this study. A 1.6-cm hypodense lesion in the upper pole of the right kidney, is not characterized in this study and can be assessed further with ultrasound. The stomach, small and large bowel loops including the appendix are normal. The abdominal aorta has moderate atherosclerotic calcifications without aneurysmal dilation. There is no abdominal free fluid or air. CT OF THE PELVIS WITH INTRAVENOUS CONTRAST: The urinary bladder, rectum and sigmoid colon are normal. The uterus is enlarged, with a round area of coarse calcifications along the right lateral aspect indicative of a calcified uterine fibroid, measuring 3.8 cm. A small amount of air is seen within the endometrial cavity. The ovaries are unremarkable. There is mild asymmetric stranding and hypoattenuation of the right gonadal vein (2: 37) compared to the left side, raising concern for possible gonadal vein thrombosis. No tubo-ovarian abscess is identified. No pelvic fluid collection is detected. No significant pelvic lymphadenopathy is seen. BONES AND SOFT TISSUES: No bone lesions suspicious for infection or malignancy are detected. Bilateral sacroiliac joint degenerative changes are seen. Moderate degenerative changes are seen in the lumbar spine with large anterior osteophyte formation. IMPRESSION: 1. In this patient with history of endometritis and Actinomyces infection, there is no evidence of tubo-ovarian abscess. Lobulated enlarged uterus, most likely due to uterine fibroids. A small amount of air within the endometrial cavity relates to the recent intervention. 2. Adnexa are unremarkable except for mild asymmetric enlargement/hypoenhancement and fat stranding surrounding the right gonadal ___ suggest right gonadal vein thrombosis. 3. Hypodense lesions in the left lobe of the liver and upper pole of the right kidney are not characterized in this study and an ultrasound is recommended for further evaluation. CXR ___: Heart size and mediastinum are unchanged. Abandoned pacemaker leads projecting over the left hemithorax is unchanged. Small amount of bilateral pleural effusion is unchanged. The right midline tip is projecting at the same location. It is unclear if it is located within the subclavian vein. Renal/liver Ultrasound ___: : The right kidney measures 10.3 cm. The left kidney measures 10.4 cm. Neither kidney demonstrates hydronephrosis or stones. Arising from the upper pole of the right kidney, there is an avascular anechoic round lesion measuring 1.9 x 1.6 x 1.8 cm, which most likely represents a cyst. Arising from the interpolar region of the left kidney, there is a 1.2 x 0.8 x 1.1 cm avascular anechoic lesion, which likely represents a cyst. The urinary bladder is nearly decompressed and therefore incompletely evaluated. IMPRESSION: Bilateral renal cysts. No focal liver lesions are detected; the lesion seen in the left lobe of the liver on CT is likely obscured by bowel gas on this examination. The liver demonstrates normal echotexture. The main portal vein is patent with hepatopetal flow. There is no intra- or extra-hepatic biliary ductal dilation. The gallbladder demonstrates no evidence for acute inflammation. There is an 8 mm stone or polyp within the gallbladder. No ascites is detected. The visualized portion of the inferior vena cava is unremarkable. IMPRESSION: 1. Left liver lesion obscured by bowel gas. MRI could be performed to evaluate this lesion. 2. 8 mm gallbladder stone or polyp. <MEDICATIONS ON ADMISSION> Tylenol ___ q8hours Neurontin 100mg qhs Amlodipine 10mg daily Plavix 75mg daily Niacin SR 500 daily ___ 320 mg daily Aspirin 81mg daily Protonix SR 40mg daily Labetalol 400mg bid crestor 40mg daily Furosemide 20mg bid <DISCHARGE MEDICATIONS> 1. Penicillin G Potassium 3 Million Units IV Q4H 2. gabapentin 100 mg Capsule Sig: One (1) Capsule PO HS (at bedtime). 3. amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 4. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. niacin 500 mg Capsule, Extended Release Sig: One (1) Capsule, Extended Release PO DAILY (Daily). 6. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 7. labetalol 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 8. rosuvastatin 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 9. furosemide 40 mg Tablet Sig: Two (2) Tablet PO QAM. 10. insulin glargine 100 unit/mL Solution Sig: Fourteen (14) UNITS Subcutaneous at bedtime. Disp: *200 UNITS* Refills: *1* 11. Humalog 100 unit/mL Solution Sig: One (1) UNIT Subcutaneous prn meals : Please use attached sliding scale . Disp: *100 UNITS* Refills: *2* 12. Normal Saline Flush 0.9 % Syringe Sig: One (1) syringe Injection prn as needed for flush. Disp: *30 syringe* Refills: *1* 13. ferrous sulfate 325 mg (65 mg iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp: *30 Tablet(s)* Refills: *2* 14. ___ PICC care per facility protocol 15. furosemide 40 mg Tablet Sig: One (1) Tablet PO at bedtime. <DISCHARGE DISPOSITION> Extended Care Facility: ___ <DISCHARGE DIAGNOSIS> Actinomyces infection of the endometrium <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Ms. ___, you were admitted to the Gynecology service for intravenous antibiotics and placement of a ___ line for treatment of your chronic endometritis. You were also found to have uncontrolled diabetes and seen by the ___ doctors. ___ kidney doctors also saw ___ due to kidney injury from CT contrast. * Please take your antibiotics as scheduled * Weigh yourself every morning, call MD if weight goes up more than 3 lbs. * Your home dose of Lasix (Furosemide)was changed from 20mg twice a day to 80mg in the morning and 40mg in the evening. Please do not take your home medication named ___ until the kidney doctors say it is okay to do so.
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Ms. ___ was admitted to the Gynecology service for further managment of Actinomyces endometrial infection and multiple medical problems 1) Actinomyces infection: The Infectious Disease service was consulted for recommendations regarding type and duration of antibiotic therapy. A CT scan was negative for pelvic extension of infection. Per their recommendations, the patient was started on IV Penicillin 3 million units every ___ hours for 4 weeks. A PICC line was placed in order to facilitate outpatient IV antibiotics. The patient will follow up in Infectious Disease Clinic as well as with Gynecology for a repeat endometrial biopsy in 4 weeks. Infectious Disease has recommended weekly labs (see Page 1) to be monitored on the patient. 2) Incidental Imaging Findings: - Ms. ___ was noted to have incidental renal and liver lesions on her CT scan. A subsequent renal and liver ultrasound was noteable for benign findings (please see ultrasound report). - There was a question of possible right gonal vein thrombosis on CT scan. Hematology was consulted regardng this. Given the patient's rising creatinine due to CT contrast (see below), no further contrast imaging could be obtained to confirm the thrombosis. Hematology recommended against anticoagulation given questional findings on CT. 3) Renal: The patient was noted to have an increase in creatinine after receiving CT contrast. Her creatinine peaked at 2.1 (baseline 1.1 on admission). The renal service was consulted. A FeNa of 0.7% was consistent with contrast induced nephropathy. Given evidence of volume overload on exam, the patient's Lasix dose was increased per renal recs to 80mg in the morning and 40mg in the evening. Her creatinine trended down to 2.0 and was stable on discharge. Her creatinine will need to be monitored on a daily basis at the outside facility. 4) Pulmonary: The patient had a Chest xray confirming small bilateral pleural effusions. On Hospital day 2 she reported shortness of breath. At that point she was satting 96-100% on room air. Her symptoms improved with 2 L nasal cannula, her lasix was adjusted as above. Her shortness of breath was resolved by hospital day #4 and she continued to sat well on room air. 5) Type 2 Diabetes: Ms. ___ was not taking any medications for this prior to her admission due to an episode of hypoglycemia. Due to elevated blood sugars on arrival, the ___ diabetes team was consulted for recommendations. Ms ___ was started on 14 units of Glargine (Lantus) nightly, with additional coverage with a Humalog sliding scale (please see attached sliding scale). Ms. ___ was discharged to an extended care facility on hospital day #5 in stable condition. She will need to continue IV Penicillin until ___. She will also need Lasix 80 mg AM and 40mg ___. Her home ___ should be held. Her creatinine should be checked on a daily basis.
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11047741-DS-19
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> lisinopril <ATTENDING> ___. <CHIEF COMPLAINT> Right upper extremity DVT, actinomyces endometritis <MAJOR SURGICAL OR INVASIVE PROCEDURE> ___ line placement <HISTORY OF PRESENT ILLNESS> ___ s/p recent GYN admission for actinomyces endometritis ___ retained IUD who presented to ED this evening with non-functional PICC line and right shoulder discomfort. Ultrasound in ED with evidence of RUE DVT. Patient was started on a heparin drip in ED and transferred to GYN service. Ms. ___ reports mild right shoulder discomfort although "better than it was yesterday. No SOB/CP/abd pain/vaginal discharge/VB. +bilateral leg swelling although not painful. <PAST MEDICAL HISTORY> PAST MEDICAL & SURGICAL HISTORY: 1. Type 2 diabetes mellitus (treated with oral hypoglycemics and Lantus, however patient stopped both of these recently due to an episode of hypoglycemia) 2. Hypertension 3. Hyperlipidemia 4. Asthma (in childhood) 5. History of recurrent angioedema secondary to medications (including ACE inhibitor) 6. Coronary artery disease (s/p CABG-triple vessel ___ 7. Congestive heart failure (P-MIBI in ___ - moderate, fixed myocardial perfusion defects involving anterolateral, lateral, and inferolateral walls; global hypokinesis; EF of 34%) 8. Left parietal stroke <SOCIAL HISTORY> Patient was admitted from a rehabilitation facility following her recent hospital stay. However, she usually lives at home with by herself with the assistance of an aide and is currently unemployed; visits a senior program daily. Denies tobacco use or alcohol use; no recreational substance use. Utilizes a walker or cane for ambulation and is functional in most ADLs. <PHYSICAL EXAM> On admission ___ by Dr. ___: VS- 98.6, 133/63, 91, 18, 97%RA Gen: no acute distress CV: RRR Pulm: +insp crackles bilaterally, otherwise CTA Abd: soft, ND, NT, no R/G Extr: 3+ ___ edema bilaterally up to knees. No erythema or tenderness Right shoulder NT, no erythema or swelling <PERTINENT RESULTS> ___ 09: 00AM BLOOD WBC-7.7 RBC-3.11* Hgb-8.4* Hct-28.1* MCV-90 MCH-27.0 MCHC-29.9* RDW-16.1* Plt ___ ___ 04: 00PM BLOOD WBC-9.2 RBC-3.34* Hgb-8.8* Hct-29.9* MCV-90 MCH-26.5* MCHC-29.6* RDW-16.2* Plt ___ ___ 09: 00AM BLOOD ___ PTT-84.9* ___ ___ 06: 25PM BLOOD ___ PTT-150* ___ ___ 04: 00PM BLOOD ___ PTT-150* ___ ___ 09: 00AM BLOOD Glucose-95 UreaN-30* Creat-1.5* Na-140 K-4.1 Cl-101 HCO3-29 AnGap-14 ___ 04: 00PM BLOOD Glucose-297* UreaN-29* Creat-1.5* Na-133 K-3.9 Cl-95* HCO3-26 AnGap-16 ___ 09: 00AM BLOOD Calcium-9.1 Phos-4.1 Mg-2.1 Right upper extremity ultrasound: Deep venous thrombosis within the right axillary vein surrounding the PICC. ___ 01: 48PM BLOOD WBC-5.7 RBC-2.85* Hgb-7.9* Hct-25.6* MCV-90 MCH-27.7 MCHC-30.9* RDW-17.2* Plt ___ ___ 01: 48PM BLOOD Plt ___ ___ 01: 48PM BLOOD ___ PTT-39.5* ___ ___ 01: 48PM BLOOD LMWH-0.37 ___ 01: 33PM BLOOD LMWH-0.55 ___ 01: 30PM BLOOD LMWH-0.20 ___ 01: 48PM BLOOD Glucose-140* UreaN-38* Creat-1.6* Na-139 K-4.2 Cl-100 HCO3-31 AnGap-12 ___ 05: 14AM URINE Eos-NEGATIVE ___ 05: 09AM URINE Hours-RANDOM Creat-34 Na-76 K-47 Cl-71 <MEDICATIONS ON ADMISSION> Penicillin G Potassium 3 Million Units IV Q4H Gabapentin 100 mg QHS Amlodipine 5 mg , 2 tabs daily Clopidogrel 75 mg PO daily Niacin 500 mg Capsule, Extended Release daily ASA 81 mg Tablet daily Labetalol 200 mg Tablet 2 tabs PO BID Rosuvastatin 20 mg Tablet 2 tabs daily Furosemode 80mg qAM, 40mg qPM Insulin Glargine 14 units at bedtime Humalog sliding scale <DISCHARGE MEDICATIONS> 1. furosemide 40 mg Tablet Sig: Three (3) Tablet PO once a day. Tablet(s) 2. insulin lispro 100 unit/mL Solution Sig: sliding scale units Subcutaneous for coverage of high ___. 3. insulin glargine 100 unit/mL Solution Sig: Fourteen (14) units Subcutaneous once a day. 4. ferrous sulfate 300 mg (60 mg iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. gabapentin 100 mg Capsule Sig: One (1) Capsule PO HS (at bedtime). 6. amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 7. niacin 500 mg Capsule, Extended Release Sig: One (1) Capsule, Extended Release PO DAILY (Daily). 8. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 9. labetalol 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 10. rosuvastatin 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 11. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 12. warfarin 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. acetaminophen 325 mg Tablet Sig: ___ Tablets PO Q6H (every 6 hours) as needed for Pain. 14. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush PICC, non-heparin dependent: Flush with 10 mL Normal Saline daily and PRN per lumen. 15. Outpatient Lab Work Complete metabolic panel every 3 days, please also fax to ___ (Dr. ___ 16. Outpatient Lab Work INR on ___ and afterwards per MD to monitor coumadin dosing, please also fax to Dr. ___ ___ 17. Outpatient Lab Work Once weekly complete metabolic panel with CBC/differential and LFTS, ESR, CRP to be faxed to the ID office ___ and to Dr. ___ ___ 18. penicillin G potassium 5 million unit Recon Soln Sig: Three (3) million units Injection once a day. Disp: *21 doses* Refills: *0* <DISCHARGE DISPOSITION> Extended Care Facility: ___ <DISCHARGE DIAGNOSIS> Right upper extremity DVT. Actinomyces endometritis. <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> You were admitted to the hospital for a blood clot in your right arm where you PICC line was. Your right PICC line was removed and you were started on anticoagulation medication to prevent further clot formation. You will need daily labs to monitor your blood levels (INR). You will follow-up with your primary care doctor once you leave the rehabilitation facility for management of your coumadin. You were previously hospitalized for an infection of your uterus that requires IV antibiotics through a PICC line. A new PICC line was placed in your left arm. You should continue the penicillin antibiotic for at least 3 more weeks. The infectious disease doctors ___ help with this. Please take your antibiotics and coumadin as scheduled. Your creatinine also rose a little bit during this hospitalization. This may be due to an exacerbation of your chronic heart failure. We spoke with the kidney doctors and they suggested that we modify the dose of your diuretic. The dose was changed FROM 80mg in the morning and 40mg at night TO furosemide (Lasix) 120mg daily. Your nursing home needs to monitor your weight and ins and outs daily. We will need you to get labs drawn every 3 days to monitor these levels so the doses can be adjusted. * Weekly CBC with differential, complete metabolic panel including LFTs, ESR, CRP. Please fax these results to the infectious disease clinic at ___. * Every 3 days a complete metabolic panel will need to be drawn. This will need to be monitored by the doctors at rehab, and your lasix dose will need to be modified. * Your ins and outs will be monitored, and the goal is net negative ___.
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Ms. ___ was admitted to the gyn service for treatment of her right upper extremity DVT. *) RU extremity DVT: pt was initially started on a heparin gtt in the ED which was later stopped and she was started on lovenox and coumadin. Her home plavix and aspirin were stopped; the aspirin was ultimately re-started. Her right PICC line was pulled upon arrival to the floor. Heme was consulted regarding management of anticoagulation given her CRI, obesity, and age. They recommended following the LMWH levels in order to properly dose it. A new PICC line was placed by ___ in the left. She finally was therapeutic on coumadin and the lovenox was discontinued. She will have her INR monitored in rehab and the dose of coumadin adjusted accordingly. *) Actinomyces infection: The Infectious Disease service was consulted for recommendations regarding type and duration of antibiotic therapy. Per their recommendations, the patient continued IV Penicillin 3 million units every 4 hours and should continue for a total of 4 weeks. A left PICC line was placed in order to facilitate outpatient IV antibiotics. The patient will follow up in Infectious Disease Clinic as well as with Gynecology for a repeat endometrial biopsy. Infectious Disease has recommended weekly labs (see Page 1) to be monitored on the patient. *) Type 2 Diabetes: Ms. ___ was not taking any medications for this prior to her admission due to an episode of hypoglycemia. While in the hospital she was written for an insulin sliding scale (see attached) and continued on her glargine 14 units at night. *) Renal insufficiency: Her baseline creatinine had been slightly elevated at 1.1-1.4 prior to the last admission; it was elevated on discharge then and felt to be likely to contrast. Her lasix had been increased at that admission. During this hospitalization, her creatinine was 1.5 on admission and crept up to 1.8. A FeNA was 1.8. We re-consulted renal and they changed the lasix dose to 120/day. They also recommended keeping track of I/O and keeping the patient net negative by 1.0 to 1.5 L/day. They recommend also daily weights and Q3day Chem 10 to monitor renal function. They felt that these changes were likely related to a CHF exacerbation.
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11048485-DS-2
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Cephalosporins <ATTENDING> ___. <CHIEF COMPLAINT> weakness <MAJOR SURGICAL OR INVASIVE PROCEDURE> none <HISTORY OF PRESENT ILLNESS> ___ y/o G1P0 ___ ___ presents to ob triage from the office with the complaint of feeling weak and trouble concentrating, ___ 87 and BP 90/60. She was given juice and sent to triage. She states that on ___ she called w/ the complaint of a HA, felt fatigued and hot, temp was 99 PO, no sick contacts. It was suggested to take tylenol, balanced diet, and po fluids. Here in triage the pt reports HA, feeling weak, episodes of "blackouts", and some visual changes. When discussed with the pt about what she ate today she reports having breakfast that consisted w/tea and toast. Currently she denies contractions, vaginal bleeding, leaking of fluid, and good fetal movements. <PAST MEDICAL HISTORY> PRENATAL COURSE (1) Dating ___ ___ (2) Labs: B pos/Ab neg (3) transfer from ___ at 25+2 wks gestation (4) hx DVT, heterozygote prothrombin mutation - on Lovenox 40 mg sq q day. PAST OBSTETRIC HISTORY G1P0 PAST MEDICAL HISTORY - Heterozygote prothrombin gene mutation - MVP dx in ___, no echo done here PAST SURGICAL HISTORY appendectomy <SOCIAL HISTORY> ___ <FAMILY HISTORY> non-contributory <PHYSICAL EXAM> GENERAL: -soft and weak voice -appears withdrawn and unable to negotiate ambulation on own but no accute distress. VITALS: Temp 98, RR 18, O2 sat 99% BP 92/62 sitting HR 71 repeat 108/63 HR 73 76/41 lying HR 71 NEURO: Cll-CXll grossly intact EOM: intact HEART: RRR S1S2 no m/g/r LUNGS: CTA B ABDOMEN: gravid, soft, nontender, -CVAT EXTREMITIES: - edema B EFM: 130 ___, AGA TOCO: no contractions noted TA U/S: BPP ___, AFI 16.3 cm, placenta anterior, fetus in vtx position, fetal cardiac motion seen. SVE: deferred ___: HEAD MRA Impression: Normal MRI of the head without gadolinium ___: NECK MRA Impression: Normal MRA of the neck ___: HEAD MRA/MRV Impression: 1. Normal MRA head. 2. Normal MRV head. ___: CARDIAC ECHO - Normal global and regional biventricular systolic function. No diastolic LV dysfunction, pulmonary hypertension, or significant valvular disease seen. ___ CERVICAL SPINE MRI 1. Normal non-contrast MR exam of the visualized spinal cord. Specifically, no evidence of MS. 2. Reversal of the normal cervical lordosis and mild kyphosis with apex at the C4-5 level where there is also mild central disc bulging without significant narrowing of the spinal canal or neural foramen. <PERTINENT RESULTS> ___ WBC-9.8 RBC-4.18 Hgb-12.6 Hct-36.4 MCV-87 Plt-173 ___ WBC-6.9 RBC-3.49 Hgb-10.8 Hct-30.1 MCV-86 Plt-162 ___ Hct-31.6 ___ Glu-73 BUN-9 Cre-0.5 Na-134 K-4.4 Cl-102 HCO3-23 ___ Glu-84 BUN-4 Cre-0.4 Na-139 K-3.9 Cl-111 HCO3-21 ___ ALT-16 AST-17 CK(CPK)-26 TotBili-0.1 ___ Calcium-8.2 Phos-3.2 Mg-2.0 ___ Albumin-2.8 Calcium-7.8 Phos-3.2 Mg-1.9 ___ TSH-1.9 ___ URINE Bld-NEG Nit-NEG Pro-NEG Glu-NEG Ket-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-LG RBC-4 WBC-22 Bacteri-FEW Yeast-NONE Epi-8 ___ URINE CULTURE neg <MEDICATIONS ON ADMISSION> Lovenox 40mg sc daily <DISCHARGE MEDICATIONS> Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed. <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> pregnancy at 29wks gestation generalized weakness <DISCHARGE CONDITION> stable; improved. s/p Physical therapy consult <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Call physician ___ : decreased fetal movement, bleeding, abdominal pain, loss of fluid or fever greater than 100.4 or other concerns.
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___ G1P0 admitted at 28+6 weeks gestation with generalized weakness, lightheadedness, and presyncope. . Mrs ___ had no obstetric concerns on arrival to labor and delivery. She appeared clinically stable with reassuring fetal testing. Labwork and vitals were within normal limits and she had no signs or symptoms of infection. Medicine was consulted and they felt that her presentation was mostly consistent with a viral syndrome and dehydration/orthostasis. However, due to her history of prothrombin gene mutation currently on Lovenox, she was at risk for a clot or bleed, therefore they recommended a cardiac workup as well as a neurology consult. Her cardiac workup was negative and included an EKG and echocardiogram, and she had no events on telemetry. Neurology evaluated her and their physical exam findings were significant for diplopia and extensor plantar response on the right. Exam was also notable for primarily giveway weakness in no clear upper or lower motor neuron pathway. She underwent multiple MRI's, including head, neck, and cervical spine, all of which were within normal limits. Neurology ultimately felt that her symptoms were nonorganic in nature. She had an uneventful hospital course, however, she continued to report right sided weakness. Neuro-ophthalmology was also consulted due to her diplopia. There was no evidence of cranial nerve palsy by their evaluation. Please see consultation notes in OMR for further details. Fetal testing was reassuring during the entire admission and she reported no contractions. Mrs ___ was frustrated that no clear etiology was established and also expressed concern that her mother was unable to visit from ___. Social services met with her and discussed these particular stresses. . On hospital day #5, physical therapy evaluated Mrs ___ and ___ that she was not stable for discharge home. They showed her some exercises and she was able to ambulate better with her husband's ___. She was making good progress by the following day and was stable for discharge. She was encouraged to obtain a PCP and will also follow up at her next OB appointment. She was also encouraged to continue outpatient physical therapy.
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11049938-DS-12
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Compazine <ATTENDING> ___ <CHIEF COMPLAINT> bleeding, cramping <MAJOR SURGICAL OR INVASIVE PROCEDURE> none <HISTORY OF PRESENT ILLNESS> 32 G4P3 at 18+6 transferred from the ED. The pt reports 2 days of vaginal bleeding, starting with passage of large clots, then some lighter bleeding. She has also had cramping pain, at times significant. Denies fever/chills, dysuria, other signs of infection. In the ED, a TVUS was performed which showed (wet read): "Single live IUP. Cervix incompetent with clot at internal os. Active contractions. As best can be determined, cervical length approx 7mm. No previa or placental abruption. Findings highly consistent with preterm labor. AFI grossly normal making PROM unlikely." <PAST MEDICAL HISTORY> PRENATAL COURSE - ___ ___ by LMP - Benign PNC - had not yet had FFS - O+/Ab-/RPRNR/RI/HBsAg- - Likely CHTN - booking BP 148/90 at 6+5 wks PAST OBSTETRIC HISTORY - NOTE: Pt reports that 2 of her children were born at ___ months", though OMR records say that deliveries were "full term", and weights as below. Year Sex ___. Birth Labor Place Type Age: Wt: Birth Del. ___ f ___ ___ c/s ___ f ___ ___ c/s ___ f ___ ___ c/s PAST MEDICAL HISTORY Anxiety, panic attacks PAST SURGICAL HISTORY C/S x 3 <SOCIAL HISTORY> ___ <FAMILY HISTORY> non-contributory <PHYSICAL EXAM> VITALS: T 99.1, HR 83, BP 128/75, RR 20 GENERAL: NAD ABDOMEN: +Uterine tenderness, no upper abd or CVAT SSE: moderate amount white discharge, GC/CT obtained, cervix very high, facing posterior, could not assess cervical dilation visually, no blood in vault SVE: cervix extremely high, ext os 1cm, could not reach int os FHR 160 <PERTINENT RESULTS> ___ WBC-7.7 RBC-3.72 Hgb-11.7 Hct-33.1 MCV-89 Plt-281 ___ Neuts-59.6 ___ Monos-5.3 Eos-0.7 Baso-0.8 ___ WBC-7.5 RBC-3.77 Hgb-11.7 Hct-34.7 MCV-92 Plt-294 ___ ___ PTT-28.8 ___ ___ ___ PTT-28.2 ___ ___ Glu-82 BUN-5 Cre-0.5 Na-139 K-3.7 Cl-107 HCO3-22 ___ URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-80 Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-TR Chlamydia trachomatis, Nucleic Acid Probe, with Amplification (Final ___: Negative for Chlamydia trachomatis by PCR. NEISSERIA GONORRHOEAE, NUCLEIC ACID PROBE, WITH AMPLIFICATION (Final ___: Negative for Neisseria Gonorrhoeae by PCR. URINE CULTURE (Final ___: MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION <MEDICATIONS ON ADMISSION> PNV - was on Prozac, Klonipin but stopped during pregnancy <DISCHARGE MEDICATIONS> 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation. <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> threatened abortion <DISCHARGE CONDITION> good <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> pelvic rest
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32 G4P3 admitted at 18+6 weeks with bleeding, cramping, short cervix. . Mrs ___ had no further vaginal bleeding on arrival to labor and delivery. Her cervix was 1cm dilated at the external os and the internal os could not be reached on exam. Fetal heartrate was 160 by doppler. She had mild uterine tenderness. Abruption labs were normal. Urine and cervical cultures were negative. She was admitted for observation and ___ consult. Dr ___ and ___ expectant management as there is no efficacious treatment at 18wks gestation. She remained stable with no further bleeding and was discharged home on hospital day #3. She will continue bedrest at home and have close outpatient followup.
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11049938-DS-13
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Compazine <ATTENDING> ___. <CHIEF COMPLAINT> Scheduled c-section <MAJOR SURGICAL OR INVASIVE PROCEDURE> cesarean delivery <HISTORY OF PRESENT ILLNESS> ___ yo G5 P4 at 39 weeks EGA for repeat c/s with tubal ligation. ___ did not want to schedule prior to this week due to oldest daughter's prom last week. <PAST MEDICAL HISTORY> PMHx: anxiety PSHx: c/s x4 , breast surgery ___ POBHx: ___ <SOCIAL HISTORY> ___ <FAMILY HISTORY> non-contributory <PHYSICAL EXAM> Exam on admission: General: NAD Cardiac: RRR Pulm: CTA Abdomen: soft, gravid, NT, 3800gmEFW by ___, VTX SVE: deferred Extr: 2+ patellar DTRs, 1+ edema FHT 140,s RLQ <PERTINENT RESULTS> ___ 09: 45AM BLOOD WBC-8.3 RBC-2.43*# Hgb-7.6*# Hct-22.6*# MCV-93 MCH-31.1 MCHC-33.5 RDW-15.9* Plt ___ ___ 07: 00PM BLOOD Hct-17.4*# ___ 12: 00PM BLOOD WBC-7.4 RBC-3.33* Hgb-10.5* Hct-32.2* MCV-97 MCH-31.5 MCHC-32.6 RDW-16.2* Plt ___ <MEDICATIONS ON ADMISSION> PNV <DISCHARGE MEDICATIONS> 1. simethicone 80 mg Tablet, Chewable Sig: ___ Tablet, Chewables PO QID (4 times a day) as needed for Dyspepsia. Disp: *60 Tablet, Chewable(s)* Refills: *2* 2. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp: *60 Tablet(s)* Refills: *2* 3. ibuprofen 600 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for pain. Disp: *40 Tablet(s)* Refills: *1* 4. Percocet ___ mg Tablet Sig: ___ Tablets PO every six (6) hours as needed for pain. Disp: *30 Tablet(s)* Refills: *0* 5. Colace 100 mg Capsule Sig: One (1) Capsule PO once a day as needed for constipation. Disp: *14 Capsule(s)* Refills: *1* 6. Iron (ferrous sulfate) 325 mg (65 mg iron) Tablet Sig: One (1) Tablet PO twice a day. Disp: *60 Tablet(s)* Refills: *1* <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> repeat cesarean delivery post partum tubal ligation <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> please see nursing instruction sheets prescriptions were given at time of last appointment
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Ms. ___ presented to L+D for scheduled repeat classical cesarean section. Please see operative note for full details. Afterwards she was admitted to the post-partum service. . On post-op day 3 she had a HCT drawn for the ___ program which was noted to be 17.4 (32 pre-op). Upon evaluation of the patient she was having symptoms of blood loss anemia but was hemodynamically stable and not currently having much bleeding. This was thought to be secondary to blood loss from delivery. She received 2U PRBC with appropriate rise in her HCT to 22. She otherwise had an uncomplicated post-operative course. She has had some recent stressors at home and was seen by social work while in the hospital. She was discharged home in good condition on POD4 with follow-up.
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11049938-DS-14
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Compazine <ATTENDING> ___. <CHIEF COMPLAINT> severe abdominal pain <MAJOR SURGICAL OR INVASIVE PROCEDURE> s/p classical c/s on ___ <HISTORY OF PRESENT ILLNESS> ___ yo ___ s/p scheduled repeat classical c-section and BTL on ___, c/b post-op blood loss anemia requiring 2u PRBC transfusion, presents with severe abdominal pain. This is described as severe, "all over", sharp and constant, radiating to lower back. She reports this is ongoing since discharge but has progressed and is unresponsive to percocet q4hrs and ibuprofen q6hrs. Reports nausea but no emesis, taking minimal PO. Intermittent fevers up to 101 "a couple days ago". She reports a normal bowel movement yesterday and passage of flatus. Reports normal urination, ___, but dark. Review of operative note reveals dense adhesions and inability to separate muscle/fascia/uterus, which is why direct classical was performed. Many additional sutures required for hemostasis but hemostasis obtained at the end of the case. On post-op day 3 she had a HCT drawn for the ___ program which was noted to be 17.4 (32 pre-op). Upon evaluation of the patient she was having symptoms of blood loss anemia but was hemodynamically stable and not currently having much bleeding. This was thought to be secondary to blood loss from delivery; EBL recorded was 1000cc. She received 2U PRBC with appropriate rise in her HCT to 22. She otherwise had an uncomplicated post-operative course. She has had some recent stressors at home and was seen by social work while in the hospital. She was discharged home in good condition on POD4. <PAST MEDICAL HISTORY> PMHx: anxiety PSHx: c/s x4 (see ob hx), breast surgery ___ POBHx: ___ s/p LTCS x3 at term classical CS at 24 weeks in ___ for PPROM <SOCIAL HISTORY> ___ <FAMILY HISTORY> non-contributory <PHYSICAL EXAM> On admission: T 98.6 -> 100.3 -> 101.8, HR 81, BP 145/90, RR 22, Sats 100% RA -appears to be in great deal of pain, moving slowly and gingerly, slightly increased RR (appears to be splinting) -RRR -CTAB -abdomen softly distended, exquisitely tender diffusely without focality but in general more so in epigastrium and upper abdomen than lower abdomen. mildine incision appears intact without drainage, difficult to assess for hematoma or collection given pain and distention. + guarding, no rebound. +BS. -no vaginal bleeding -no edema <PERTINENT RESULTS> ___ CT Abdomen/Pelvis: FINDINGS: The imaged lung bases demonstrate linear subsegmental right basilar atelectasis. No pleural effusion or pericardial effusion is seen. The liver enhances homogeneously, without focal lesions. There is no intra- or extra-hepatic biliary dilatation. The gallbladder is moderately distended, but no gallstones are identified. The adrenal glands, spleen, and pancreas are normal. Both kidneys enhance and excrete contrast symmetrically, without evidence of hydroureteronephrosis. The stomach, small and large bowel loops are unremarkable, without evidence of small bowel obstruction. Mild thickening of the proximal small bowel loops is likely reactive. The administered oral contrast reaches to the level of the rectum. There is no evidence of extravasation of oral contrast to suggest bowel perforation. The abdominal aorta is normal in course and caliber. Small retroperitoneal lymph nodes do not meet CT criteria for significant adenopathy. Small amount of non-serous fluid is also seen in the perihepatic and perisplenic regions. CT OF THE PELVIS: There is a large amount of partially organized hematoma in the lower abdomen and pelvis anterior to the uterus, maximally measuring approximately 12 cm (CC) x 4.3 cm (AP) x 15 cm (TR) in dimension. Small areas of liquefaction is seen within this predominantly solid hematoma. Small foci of air within the hematoma (2B: 51), relates to recent surgery. The hematoma extends from a focal discontinuity in the anterior uterine wall enhancement (2B: 56), which likely representing the ___ site. A small amount of air and fluid within the uterine cavity relates to the recent surgery. The adnexa are unremarkable. A Foley catheter is seen within the bladder, with a small amount of air secondary to it. The rectum and sigmoid colon are normal. Small amount of complex pelvic free fluid is seen. BONES AND SOFT TISSUES: No bone lesions suspicious for infection or malignancy are detected. IMPRESSION: 1. Large abdominopelvic hematoma measuring 12 x 15 x 4 cm, extending anteriorly from a focal discontinuity in the enhancement of the anterior uterine wall, corresponding to the recent Cesarean section site. 2. No acute bowel pathology. Mild reactive bowel wall thickening. ___ Abdominal Ultrasound: IMPRESSION: Heterogeneous fluid collection within the lower abdomen/pelvis consistent with hematoma without evidence of organized components, not significantly changed in size. Air within the endometrial cavity may relate to post-surgical change although this cannot be differentiated from infection in the setting of fever. ___ Interventional Radiology Ultrasound: IMPRESSION: 1. Technically successful ultrasound-guided needle aspiration of anterior intra-abdominal hematoma with aspiration of 100 cc of dark serosanguineous fluid; sample sent for microbiology studies. 2. Findings raising concern for acute cholecystitis including distention, stones and focal tenderness. Further clinical assessment of the possibility is recommended. If there is discordance between clinical findings and concerning imaging results discussed here, then hepatobiliary scanning may be helpful to evaluate further, particularly if no other potential source for infection is identified. ___ HIDA Gallbladder scan IMPRESSION: Normal hepatobiliary scan. ___ 10: 14AM BLOOD WBC-11.6* RBC-3.35*# Hgb-10.1*# Hct-31.5*# MCV-94 MCH-30.3 MCHC-32.2 RDW-15.1 Plt ___ ___ 04: 25PM BLOOD WBC-15.7* RBC-3.28* Hgb-9.9* Hct-31.3* MCV-95 MCH-30.1 MCHC-31.7 RDW-15.2 Plt ___ ___ 03: 00AM BLOOD WBC-17.5* RBC-3.14* Hgb-9.4* Hct-29.5* MCV-94 MCH-29.9 MCHC-31.8 RDW-15.1 Plt ___ ___ 05: 00PM BLOOD WBC-17.9* RBC-2.97* Hgb-9.1* Hct-28.0* MCV-94 MCH-30.6 MCHC-32.6 RDW-15.1 Plt ___ ___ 09: 20PM BLOOD WBC-18.0* RBC-2.89* Hgb-9.0* Hct-26.9* MCV-93 MCH-31.0 MCHC-33.4 RDW-15.9* Plt ___ ___ 12: 00PM BLOOD WBC-18.7* RBC-2.94* Hgb-8.8* Hct-27.8* MCV-95 MCH-30.1 MCHC-31.8 RDW-15.9* Plt ___ ___ 08: 15AM BLOOD WBC-16.7* RBC-2.85* Hgb-8.4* Hct-26.9* MCV-94 MCH-29.4 MCHC-31.2 RDW-15.3 Plt ___ ___ 04: 45AM BLOOD WBC-14.2* RBC-2.73* Hgb-8.2* Hct-25.5* MCV-93 MCH-30.0 MCHC-32.1 RDW-15.4 Plt ___ ___ 04: 45AM BLOOD WBC-14.1* RBC-2.79* Hgb-8.3* Hct-25.9* MCV-93 MCH-29.7 MCHC-32.0 RDW-15.4 Plt ___ ___ 06: 45AM BLOOD WBC-13.7* RBC-2.65* Hgb-7.6* Hct-24.8* MCV-94 MCH-28.8 MCHC-30.8* RDW-15.4 Plt ___ ___ 06: 00AM BLOOD WBC-12.5* RBC-2.60* Hgb-7.6* Hct-24.4* MCV-94 MCH-29.2 MCHC-31.0 RDW-15.5 Plt ___ ___ 10: 14AM BLOOD Neuts-81.0* Lymphs-15.0* Monos-3.1 Eos-0.5 Baso-0.3 ___ 04: 25PM BLOOD Neuts-88.0* Lymphs-8.8* Monos-2.9 Eos-0.2 Baso-0.1 ___ 09: 20PM BLOOD Neuts-85.5* Lymphs-9.1* Monos-3.2 Eos-1.7 Baso-0.4 ___ 12: 00PM BLOOD Neuts-87.1* Lymphs-8.4* Monos-3.5 Eos-0.6 Baso-0.3 ___ 08: 15AM BLOOD Neuts-83.0* Lymphs-11.6* Monos-4.1 Eos-1.0 Baso-0.2 ___ 04: 45AM BLOOD Neuts-78.3* Lymphs-14.8* Monos-5.2 Eos-1.2 Baso-0.5 ___ 06: 45AM BLOOD Neuts-74.4* Lymphs-17.5* Monos-7.6 Eos-0.3 Baso-0.3 ___ 06: 00AM BLOOD Neuts-76.0* Lymphs-16.9* Monos-6.3 Eos-0.5 Baso-0.2 ___ 10: 15AM BLOOD ___ PTT-30.1 ___ ___ 10: 15AM BLOOD ___ ___ 10: 14AM BLOOD Glucose-76 UreaN-8 Creat-0.7 Na-141 K-3.9 Cl-107 HCO3-24 AnGap-14 ___ 03: 00AM BLOOD Glucose-89 UreaN-9 Creat-0.6 Na-140 K-3.6 Cl-107 HCO3-24 AnGap-13 ___ 05: 00PM BLOOD Creat-0.6 ___ 08: 15AM BLOOD Creat-0.6 ___ 04: 45AM BLOOD Creat-0.6 ___ 10: 14AM BLOOD ALT-8 AST-12 LD(LDH)-421* ___ 03: 00AM BLOOD ALT-7 AST-13 ___ 05: 00PM BLOOD ALT-7 AST-11 ___ 08: 15AM BLOOD ALT-8 AST-12 AlkPhos-190* TotBili-0.5 ___ 10: 14AM BLOOD Lipase-38 ___ 08: 15AM BLOOD Lipase-26 GGT-58* ___ 10: 14AM BLOOD Calcium-8.7 Phos-3.9 Mg-1.9 ___ 03: 00AM BLOOD Calcium-8.1* Phos-3.7 Mg-1.7 UricAcd-4.4 ___ 05: 00PM BLOOD UricAcd-4.3 ___ 04: 45AM BLOOD Genta-0.7* ___ 2: 40 pm ABSCESS Source: abdominal hematoma. **FINAL REPORT ___ GRAM STAIN (Final ___: 3+ ___ per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. SMEAR REVIEWED; RESULTS CONFIRMED. FLUID CULTURE (Final ___: CORYNEBACTERIUM SPECIES (DIPHTHEROIDS). MODERATE GROWTH. ANAEROBIC CULTURE (Final ___: NO ANAEROBES ISOLATED. Blood cultures ___ all with no growth. Urine cultures ___ with no growth. ___ 3: 21 am STOOL CONSISTENCY: NOT APPLICABLE Source: Stool. **FINAL REPORT ___ C. difficile DNA amplification assay (Final ___: Negative for toxigenic C. difficile by the Illumigene DNA amplification assay. <MEDICATIONS ON ADMISSION> PNV <DISCHARGE MEDICATIONS> 1. Dilaudid 2 mg Tablet Sig: ___ Tablets PO every ___ hours as needed for pain for 2 weeks. Disp: *30 Tablet(s)* Refills: *0* 2. ibuprofen 600 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for pain for 4 weeks. Disp: *40 Tablet(s)* Refills: *0* 3. labetalol 200 mg Tablet Sig: One (1) Tablet PO three times a day. Disp: *90 Tablet(s)* Refills: *2* 4. Augmentin 875-125 mg Tablet Sig: One (1) Tablet PO every twelve (12) hours for 2 weeks. Disp: *28 Tablet(s)* Refills: *0* 5. Flagyl 500 mg Tablet Sig: One (1) Tablet PO three times a day for 2 weeks. Disp: *42 Tablet(s)* Refills: *0* <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> infected subfascial hematoma <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> follow routine post-operative (s/p c/s on ___ and treatment of infected hematoma instructions
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On ___ (post-operative day 9), Ms. ___ was admitted to the postpartum service for severe abdominal pain and fever, and CT scan showed a "Large abdominopelvic hematoma measuring 12 x 15 x 4 cm, extending anteriorly from a focal discontinuity in the enhancement of the anterior uterine wall, corresponding to the recent Cesarean section site", no acute bowel pathology, and moderate distended gallbladder without identifiable stones. Discussion with radiology revealed that there was not fluid pocket amenable to drainage at this time. She was therefore started on empiric IV gentamicin and clindamycin. She had persistent fever up to 103 on hospital day 2, so ampicillin was added. Gynecologic oncology consult in regards to possible need for surgical evacuation of the hematoma, recommended conservative management as re-operation would be very high risk. An abdominal ultrasound showed that the fluid collection was stable in size. On hospital day 4, she underwent ultrasound-guided drainage of the fluid collection performed by interventional radiology. 100cc of dark serosanguinous fluid was drained and at the time of the ultrasound, there appeared to be a sonographic ___ sign and thickened gallbladder wall concerning for cholecystits. She also had an episode of emesis and was made NPO and general surgery was consulted. They recommended LFTs, which were normal, and a HIDA scan which was performed on hospital day 5. This scan was normal. On hospitdal day 6, she had an episode of loose stools, so a c-diff was sent, which was negative. By that evening, she had been afebrile for over 48 hours, so she was transitioned to oral anbitiotic regiment of augmentin and flagyl. Her abdominal fluid collection eventually grew Cornebacterium, but blood and urine cultures throughout her hospital stay were no growth. By hospital day 8, she had been observed for 24 hours on oral antibiotics and had remained afebrile. At this point, she was tolerating a regular diet, voiding spontaneously, and her pain was controlled with oral medications. She was then discharged home in stable condition.
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| 460
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11049938-DS-15
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Compazine <ATTENDING> ___. <CHIEF COMPLAINT> continued abdominal pain/known fascial hematoma <MAJOR SURGICAL OR INVASIVE PROCEDURE> ultrasound-guided drainage of hematoma <HISTORY OF PRESENT ILLNESS> ___ yo ___ s/p scheduled repeat classical c-section and PPTL on___, c/b post-op blood loss anemia requiring 2u PRBC transfusion p/w continued abdominal pain. She was re-admitted on ___ with severe abdominal pain and was found to have a 12 x 15 x 4 cm subfascial poorly organized hematoma anterior to uterus. ___ guided drainage was attempted on ___ but minimal drainage was possible given the organized nature of the clot. During that hospitalization she had high fevers concerning for superinfected hematoma but the material drained did not grow any organisms. She was treated with antibiotics and analgesics. She was discharged home in stable condition on oral pain medications. She reports that she is tolerating a regular diet and having regular bowel movements and flatus now. She denies N/V. She denies continued fevers and chills. She reports the pain waxes and wanes but it is the same pain she was having in the hospital. At this time she feels it has not worsened but it remains "incredibly bad" and "intolerable." <PAST MEDICAL HISTORY> PMHx: anxiety PSHx: c/s x5, breast surgery ___ POBHx: s/p LTCS x 4 at term classical CS at 24 weeks in ___ for PPROM <SOCIAL HISTORY> ___ <FAMILY HISTORY> non-contributory <PHYSICAL EXAM> On admission: VS: 98.0, 128/76, 84, 98% RA NAD at rest but wincing in pain with movement RRR no m/g/r, nml S1,S1 CTAB Abdomen softly distended. firm fixed 10-12 cm indurated mass midline-subumbilical region which is exquisitely TTP. Surrounding abd is soft and minimally TTP. + voluntary guarding when palpating hematoma/ mass but no R/G on remaining abd exam Ext NT <PERTINENT RESULTS> ___ 05: 17PM BLOOD WBC-11.5* RBC-3.12* Hgb-8.9* Hct-28.8* MCV-92 MCH-28.6 MCHC-31.0 RDW-15.8* Plt ___ ___ 09: 13AM BLOOD WBC-10.4 RBC-3.12* Hgb-9.0* Hct-28.7* MCV-92 MCH-28.8 MCHC-31.4 RDW-16.6* Plt ___ ___ 02: 39PM BLOOD WBC-8.2 RBC-3.00* Hgb-8.5* Hct-27.8* MCV-93 MCH-28.5 MCHC-30.7* RDW-16.2* Plt ___ ___ 05: 17PM BLOOD Neuts-70.5* ___ Monos-6.3 Eos-0.3 Baso-0.3 ___ 10: 46PM BLOOD ___ PTT-34.8 ___ ___ 05: 17PM BLOOD Glucose-76 UreaN-11 Creat-0.6 Na-141 K-4.3 Cl-103 HCO3-24 AnGap-18 ___ 08: 30PM URINE Color-Yellow Appear-Hazy Sp ___ ___ 08: 30PM URINE Blood-LG Nitrite-NEG Protein-30 Glucose-NEG Ketone-10 Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-MOD ___ 08: 30PM URINE RBC-45* WBC-18* Bacteri-FEW Yeast-NONE Epi-33 ___ 08: 30PM URINE Mucous-MANY GRAM STAIN (Final ___: 4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. FLUID CULTURE (Final ___: NO GROWTH. ANAEROBIC CULTURE (Final ___: NO GROWTH. CT abdomen/pelvis ___: multiple hypodense fluid collections seen within the lower abdomen and pelvis anteriorly at the location of the previously noted large hematoma, the largest fluid collection measuring 14.5 x 8.6 cm in greatest axial ___, anterior to the uterus, demonstrating a rim enhancement as well as a debris-fluid level. Smaller, loculated fluid collections seen throughout the abdomen. A smaller rim-enhancing fluid collection is seen within the left rectus muscle measuring 2.1 x 1.7 cm. There is rim-enhancing fluid collection seen posterior to the largest fluid collection and is difficult to determine whether or not this communicates with the endometrial canal. <MEDICATIONS ON ADMISSION> Prenatal vitamins, labetalol 200 mg TID <DISCHARGE MEDICATIONS> 1. hydromorphone 2 mg Tablet Sig: ___ Tablets PO Q4H (every 4 hours) as needed for pain. 2. ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. 3. labetalol 200 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 4. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for Constipation. <DISCHARGE DISPOSITION> Home With Service Facility: ___ <DISCHARGE DIAGNOSIS> Hematoma <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Please continue to follow your postpartum discharge instructions.
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This is a ___ yo s/p repeat cesarean on ___ readmitted with persistent pain in the setting of a known 15 cm subfascial hematoma. CT of the abdomen revealed liquidification of the hematoma possibly amenable to drainage. On hospital day #1, she underwent ultrasound-guided drainage of the hematoma with drain placed. Aspirated fluid was sent for culture. Her hematocrit was stable following the procedure. She remained afebrile without a leukocytosis throughout the course of her hospitalization. She was not placed on antibiotics given antibiotic use in her previous hospitalization and no signs or symptoms of infection. Final cultures of the aspirated fluid showed no growth. She was placed on PO dilaudid, tylenol and ibuprofen for pain control. Of note, in her prior hospitalization, she had elevated blood pressures with HELLP labs within normal limits. She was continued on labetalol 200 TID throughout this hospitalization and her BP remained within the acceptable range. She was discharged on hospital day #3 with ___ services for drain care. She was in stable condition at the time of discharge with her abdominal drain in place, given continued output of serosanguinous fluid. Per the Interventional Radiology attending, her drain should remain in place until the drain output is 10 mL per day for two days. At the time of discharge, she was afebrile and tolerating PO intake. She was given instructions to follow-up with Dr. ___ 24-hours after discharge.
| 1,342
| 315
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11051753-DS-10
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> vancomycin / Bactrim <ATTENDING> ___. <CHIEF COMPLAINT> transient hand numbness and difficulty word finding, elevated BP <MAJOR SURGICAL OR INVASIVE PROCEDURE> none <HISTORY OF PRESENT ILLNESS> ___ G1P1 4 weeks s/p pLTCS on ___ in the setting of ___ with superimposed pre-eclampsia severe by HA and BP, also with T1DM, asthma, R sided Bell's palsy, currently in ED after a 20-minute episode of right hand numbness and difficulty word-finding while she was at home. She reports her blood pressure at that time was 150/100 and given her history she presented to the ED for evaluation. She initially had no HA on arrival to the ED but per ED resident she developed HA and received Tylenol, which has resulted in improvement in her HA. She denies visual changes abdominal pain. She endorses complete resolution of her RUE and speech symptoms and denies any other numbness, tingling, weakness or concerns. Regarding her history of pre-eclampsia, she was managed inpatient for several weeks prior to her delivery and was delivered for development of severe features at 35 weeks. She received IV magnesium for 24 hours following delivery and was maintained on nifedipine 60mg BID, which was continued upon discharged but tapered off by her 2 week postpartum visit. Regarding her postpartum status, she is not breastfeeding and reports only rare brown vaginal spotting, no bright red bleeding. She reports no pain, redness or drainage from her incision. Regarding her Bell's Palsy, she is s/p a 7-day course of Valtrex and prenisone and had negative Lyme serologies, reports slight improvement in her facial droop. Regarding her T1DM, she is followed by ___ and reports that recently her fingersticks have been well controlled. During her hospitalization she had multiple highs and lows and required close titration of her insulin. ROS otherwise negative except as noted in the HPI <PAST MEDICAL HISTORY> OBHx: - G1 pLTCS ___ c/b T1DM, ___ with superimposed pre-eclampsia, severe by GynHx: - Denies history of abnormal pap smears, no history of pelvic infections PMH: - TIDM - asthma - HLD - Depression - Heart murmur (diagnosed in childhood, not followed by cardiology) PSH: - pLTCS as above <SOCIAL HISTORY> ___ <FAMILY HISTORY> Father: HTN, CAD Multiple family members w/ T2DM and heart disease, and migraines <PHYSICAL EXAM> On admission: VS: T 97.7 HR 99 BP 160/87, 163/95 -> 10mg IV labetalol -> 150s/80s, SpO2 100%RA Gen: NAD CV: RRR Pulm: CTAB, normal work of breathing Abd: soft, nondistended, nontender, incision well-healed Pelvic: deferred Ext: trace edema bilaterally, symmetric, nontedner On discharge: Vitals: 98.3PO136 / 80 HR ___ General: NAD, ___ CV: RRR Lungs: No respiratory distress, CTAB Abd: soft, nontender, fundus firm Incision: clean, dry, intact, no erythema/induration Lochia: minimal Extremities: no calf tenderness, no edema Neuro: stable R bells palsy, no other deficits ___ CT IMPRESSION: No evidence for acute intracranial abnormalities. MRI would be more sensitive for an acute infarction or other acute intracranial abnormalities, if clinically warranted. ___ IMPRESSION: No acute cardiopulmonary abnormality ___ HEAD AND NECK IMPRESSION: 1. Normal CTA of the head and neck. 2. No dural venous sinus or major cortical venous thrombosis. 3. No acute intracranial findings. ___ MRI IMPRESSION: 1. No acute intracranial process such as infarct or hemorrhage. 2. No abnormal enhancement after contrast administration. <PERTINENT RESULTS> ___ WBC-8.6 RBC-3.58 Hgb-10.2 Hct-31.3 MCV-87 Plt-398 ___ Neuts-73.5 ___ Monos-6.5 Eos-1.0 Baso-0.3 Im ___ AbsNeut-6.32 AbsLymp-1.57 AbsMono-0.56 AbsEos-0.09 AbsBaso-0.03 ___ ___ PTT-29.9 ___ ___ Glu-142 BUN-14 Cre-0.6 Na-140 K-4.4 Cl-105 HCO3-19 ___ Glu-145 BUN-14 Cre-0.5 Na-140 K-4.5 Cl-106 HCO3-20 ___ ALT-22 AST-27 AlkPhos-79 TotBili-0.4 ___ ALT-21 AST-26 AlkPhos-80 TotBili-0.4 ___ cTropnT-<0.01 ___ Albumin-3.6 Calcium-9.1 Phos-3.6 Mg-1.8 ___ Albumin-3.5 Calcium-9.3 Phos-3.6 Mg-1.8 ___ %HbA1c-5.5 eAG-111 ___ LDLmeas-270* ___ TSH-1.0 ___ BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG ___ URINE Blood-TR* Nitrite-NEG Protein-100* Glucose-300* Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-TR* ___ URINE RBC-6* WBC-2 Bacteri-FEW* Yeast-NONE Epi-<1 ___ URINE bnzodzp-NEG barbitr-NEG opiates-NEG cocaine-NEG amphetm-NEG oxycodn-NEG mthdone-NEG ___ URINE UCG-NEGATIVE Blood Culture, Routine (Final ___: NO GROWTH URINE CULTURE (Final ___: MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION <MEDICATIONS ON ADMISSION> Levemir 18u am/ 18u pm Aspirin 81 mg QD Humalog sliding scale with meals ___ Albuterol PRN <DISCHARGE MEDICATIONS> 1. Verapamil SR 180 mg PO Q24H RX *verapamil 180 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills: *1 2. levemir 18 Units Breakfast levemir 18 Units Bedtime ** Insulin Carb Counting Scale ** <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> Postpartum hypertension Reversible cerebral vasoconstriction versus complicated migraine <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> ___, You were readmitted to the postpartum service given elevated blood pressure and numbness, speech loss. You had an evaluation by neurology and normal head imaging. Given your history, it was thought that your symptoms were due to a complicated migraine vs. something called reversible cerebral vasoconstriction. You should take verapamil as prescribed and follow-up with neurology as an outpatient.
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___ G1P1 with T1DM, ___ palsy superimposed severe pre-eclampsia s/p postpartum magnesium 4 weeks ago, now presenting with an acute neurologic event consisting of R hand numbness and difficulty word-finding. On arrival to the ED, her symptoms had resolved and her neurologic exam was normal with the exception of the known Bells Palsy. CBC, lytes, LFTs, and toxicology screens were negative. Although she had severe range blood pressures on arrival, there was low suspicion for an eclamptic seizure. Head imaging (including head CT and MRI) was negative. Her blood pressures improved with one dose of IV Labetalol and Magnesium was deferred. She was initially restarted on po Nifedipine CR, however, this was discontinued when neurology recommended Verapamil (180mg ER daily) given suspicion for reversible cerebral vasoconstriction. She remained clinically stable without any recurrent neurologic symptoms. Her blood pressures were well controlled (130s/80s) on Verapamil at the time of discharge. She was discharged home on ___ and will have close outpatient follow up. . In regards to her T1DM, she was continued on her home Levemir regimen. Her fingersticks were above goal intermittently, but not above 200. She will follow up with ___ as an outpatient.
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11051753-DS-8
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> vancomycin / Bactrim <ATTENDING> ___. <CHIEF COMPLAINT> n/v/hyperglycemia <MAJOR SURGICAL OR INVASIVE PROCEDURE> none <HISTORY OF PRESENT ILLNESS> ___ G1P0 at 8w0d by LMP c/w 6 week ultrasound presents to the ED with 2 days of n/v/poor po tolerance, cough and myalgias. Not able to tolerate po since midnight last night. Last insulin intake was her normal pm levemir. She did not take her normal levemir this morning. Denies VB, LOF, cramping. Denies urinary symptoms. Since presenting to ED, recieved IV hydration and zofran, now tolerating oral medications and regular diet. ROS otherwise negative. <PAST MEDICAL HISTORY> PAST MEDICAL HISTORY: 1. Asthma: Rare albuterol use. 2. T1DM; followed by ___, recent A1C 6.5% on ___ c/b diabetic oculopathy. 3. Seasonal allergies. 4. Hx RLE cellulitis: Hospitalized and treated ___ 5. Depression 6. HLD 7. heart murmur PAST SURGICAL HISTORY 1. None <SOCIAL HISTORY> ___ <FAMILY HISTORY> Father: HTN, CAD Multiple family members w/ T2DM and heart disease, and migraines <PHYSICAL EXAM> (on admission) Triage 06: 50 99.0 106 153/79 16 RA Today 10: 04 249 Today 11: 48 98.0 94 128/83 18 100% RA Today 11: 54 198 Today 13: 32 189 GENERAL: NAD HEART: RRR LUNGS: CTAB ABDOMEN: soft, nontender, nd ___: nt, ne bedside TAUS: +FH, size appears consistent with LMP dating <PERTINENT RESULTS> ___ WBC-6.5 RBC-4.03 Hgb-11.2 Hct-33.4 MCV-83 Plt-266 ___ Neuts-77.4 ___ Monos-10.5 Eos-0.5 Baso-0.8 Im ___ AbsNeut-5.03 AbsLymp-0.67 AbsMono-0.68 AbsEos-0.03 AbsBaso-0.05 ___ Glucose-290* UreaN-11 Creat-0.6 Na-134 K-4.2 Cl-98 HCO3-19 AnGap-21 ___ Glucose-143* UreaN-7 Creat-0.5 Na-133 K-3.5 Cl-99 HCO3-20 AnGap-18 ___ Glucose-168* UreaN-10 Creat-0.5 Na-136 K-3.8 Cl-101 HCO3-22 AnGap-17 ___ Calcium-8.7 Phos-2.7 Mg-1.8 ___ Calcium-9.0 Phos-3.6 Mg-1.8 ___ BLOOD ___ pO2-70 pCO2-37 pH-7.39 calTCO2-23 Base XS--1 ___ BLOOD ___ pO2-70 pCO2-35 pH-7.41 calTCO2-23 Base XS--1 Intubat-NOT INTUBA ___ BLOOD Glucose-257 ___ BLOOD Lactate-1.0 ___ BLOOD Glucose-144 ___ BLOOD O2 Sat-92 ___ URINE Blood-SM Nitrite-NEG Protein-30 Glucose-1000 Ketone-40 Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG ___ URINE RBC-12 WBC-0 Bacteri-FEW Yeast-NONE Epi-1 ___ OTHER BODY FLUID FluAPCR-POSITIVE FluBPCR-NEGATIVE URINE CULTURE (Final ___: MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION <MEDICATIONS ON ADMISSION> Levemir Humalog PNV Albuterol prn <DISCHARGE MEDICATIONS> 1. Acetaminophen ___ mg PO Q6H: PRN Pain - Mild RX *acetaminophen 500 mg ___ tablet(s) by mouth every 6 hours Disp #*25 Tablet Refills: *0 2. OSELTAMivir 75 mg PO Q12H RX *oseltamivir 75 mg 1 capsule(s) by mouth every 12 hours Disp #*8 Capsule Refills: *0 3. levemir 25 Units Breakfast levemir 34 Units Bedtime ** Insulin Carb Counting Scale ** 4. Albuterol Inhaler ___ PUFF IH Q4H: PRN asthma 5. Prenatal Vitamins 1 TAB PO DAILY <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> T1DM with hyperglycemia Influenza A <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Dear Ms. ___, You were admitted to the ___ service for hyperglycemia and influenza in the setting of your early pregnancy. You were treated with fluids, anti-nausea medications, and Tamiflu. You were also seen by the endocrinologists who made some adjustments to your insulin regimen to help maintain your blood sugar at goal. You are now safe to be discharged home. Please make sure to follow the new insulin regimen listed below: Levemir 25 units in the morning, 34 units at night Insulin to Carbohydrate Ratio: 1: 5 with breakfast 1: 6 with lunch 1: 6 with dinner Insulin sensitivity factor of 1: 40 Fasting blood glucose goal should be below 100, Post-meal blood glucose goal should be below 130 Please call your doctor if you start experiencing the following symptoms: - 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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27 G1P0 with T1DM admitted at 8w0d with poorly controlled T1DM and influenza A. On admission, she was overall well-appearing and afebrile. She had a negative CXR. She was started on a course of Tamiflu. Her nausea was treated with anti-emetics and her symptoms improved. In regards to her T1DM, she had hyperglycemia ___ 290) with a low bicarbonate (19) and normal ___ was consulted and followed her. It was felt her hyperglycemia was due to her acute illness and omission of morning insulin, less likely DKA. Her labs improved and her fingersticks were much improve once she was tolerating a regular diet on HD#2. Only small changes in her insulin regimen were recommended. She remained clinically stable and was discharged home on ___. She will have close outpatient follow up.
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11051753-DS-9
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> vancomycin / Bactrim <ATTENDING> ___. <CHIEF COMPLAINT> swelling, headache <MAJOR SURGICAL OR INVASIVE PROCEDURE> Cesarean delivery <HISTORY OF PRESENT ILLNESS> Ms. ___ was ___ G1P0 at 24w5d with gHTN and TIDM, when she presented with swelling and headache. The patient had been followed for gestational hypertension, was started on nifedipine for elevated pressures. She had a baseline PIH labs done in ___, which were normal, as well as a 24 hour urine protein on ___, which was elevated at 512. On presentation, she reported having leg swelling for the past 2 weeks, with pitting edema on her anterior shins the night prior to presentation. She also developed a stabbing headache the same night, that was unrelieved by Tylenol. She was seen at ___ ___, found to have normal PIH labs, and blood pressure 136/75. She otherwise denied contractions, VB, LOF and noted active fetal movement. A 24 hour urine was obtained and ___ was consulted. <PAST MEDICAL HISTORY> PNC: - ___ ___ by ___ - Labs ___ unknown - Screening LR panorama - FFS normal - Issues: -->TIDM -->gHTN with baseline 24 hour protein 512 (___) OBHx: - G1 current GynHx: - Denies history of abnormal pap smears, no history of pelvic infections PMH: - TIDM - asthma - HLD - Depression - Heart murmur (diagnosed in childhood, not followed by cardiology) PSH: denies <SOCIAL HISTORY> ___ <FAMILY HISTORY> Father: HTN, CAD Multiple family members w/ T2DM and heart disease, and migraines <PHYSICAL EXAM> On admission: Vitals: ___ ___: 149 ___ 20: 42BP: 146/81 (96) ___ 20: 45BP: 140/79 (95) ___ 20: 50BP: 144/82 (96) ___ 20: 55BP: 136/76 (91) Gen: ___, comfortable CV: RRR PULM: CTAB Abd: soft, gravid, nontender Ext: no calf tenderness Toco: quiet FHT 130/moderate varability/+accels/? rare, shallow variable decels Bedside ultrasound: MVP 4cm, active fetal movement On discharge: VS: 98.1 143/89 ___ BP range ___ General: NAD, ___ Lungs: No respiratory distress Abd: soft, nontender, fundus firm below umbilicus. nontender Incision: clean, dry, intact, no erythema/induration Extremities: no calf tenderness, no edema <PERTINENT RESULTS> Labs on Admission: ___ 09: 02PM BLOOD WBC-12.7*# RBC-3.39* Hgb-9.9* Hct-28.3* MCV-84 MCH-29.2 MCHC-35.0 RDW-12.6 RDWSD-38.5 Plt ___ ___ 06: 03AM BLOOD WBC-14.3* RBC-3.35* Hgb-9.8* Hct-28.4* MCV-85 MCH-29.3 MCHC-34.5 RDW-12.7 RDWSD-38.5 Plt ___ ___ 09: 02PM BLOOD Plt ___ ___ 06: 03AM BLOOD Plt ___ ___ 12: 26PM BLOOD ___ ___ 09: 02PM BLOOD Creat-0.5 ___ 02: 45PM BLOOD Glucose-268* UreaN-13 Creat-0.5 Na-135 K-3.9 Cl-103 HCO3-21* AnGap-15 ___ 09: 18PM BLOOD Glucose-168* UreaN-13 Creat-0.6 Na-135 K-4.1 Cl-100 HCO3-22 AnGap-17 ___ 09: 02PM BLOOD ALT-29 AST-22 ___ 06: 03AM BLOOD ALT-26 AST-14 ___ 07: 40AM BLOOD ALT-23 AST-14 ___ 09: 02PM BLOOD UricAcd-3.7 ___ 02: 45PM BLOOD Calcium-9.2 Phos-2.8 Mg-1.7 ___ 09: 02PM URINE Color-Yellow Appear-Hazy Sp ___ ___ 09: 02PM URINE Blood-TR Nitrite-NEG Protein-100 Glucose-500 Ketone-15 Bilirub-NEG Urobiln-1 pH-6.5 Leuks-TR ___ 09: 02PM URINE RBC-3* WBC-7* Bacteri-MOD Yeast-NONE Epi-2 TransE-<1 ___ 09: 02PM URINE Hours-RANDOM Creat-63 TotProt-54 Prot/Cr-0.9* ___ 11: 58PM URINE 24Creat-1502 24Prot-1108 ___ 01: 14PM URINE 24Creat-1862 24Prot-760 **FINAL REPORT ___ R/O GROUP B BETA STREP (Final ___: POSITIVE FOR GROUP B BETA STREP. Please contact the Microbiology Laboratory (___) immediately if sensitivity testing to clindamycin is required on this patient's isolate. Relevant Labs: ___ 1: 00 pm URINE Source: ___. **FINAL REPORT ___ URINE CULTURE (Final ___: MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION. ___ 11: 20 am URINE Source: ___. **FINAL REPORT ___ URINE CULTURE (Final ___: MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION. ___ 12: 26 pm Blood (LYME) **FINAL REPORT ___ Lyme IgG (Final ___: NEGATIVE BY EIA. (Reference Range-Negative). Lyme IgM (Final ___: EQUIVOCAL BY EIA. (Reference Range-Negative). EIA RESULT NOT CONFIRMED BY WESTERN BLOT. NEGATIVE BY WESTERN BLOT. Refer to outside lab system for complete Western Blot results. Negative results do not rule out B. burg___ infection. Patients in early stages of infection or on antibiotic therapy may not produce detectable levels of antibody. Labs on Discharge: ___ 06: 26PM BLOOD WBC-15.4* RBC-3.55* Hgb-10.9* Hct-30.0* MCV-85 MCH-30.7 MCHC-36.3 RDW-13.9 RDWSD-41.8 Plt ___ ___ 10: 45AM BLOOD WBC-14.6* RBC-3.37* Hgb-10.2* Hct-28.7* MCV-85 MCH-30.3 MCHC-35.5 RDW-13.9 RDWSD-41.8 Plt ___ ___ 06: 26PM BLOOD Plt ___ ___ 10: 45AM BLOOD Plt ___ ___ 06: 26PM BLOOD Creat-0.5 ___ 10: 45AM BLOOD Creat-0.6 ___ 06: 26PM BLOOD ALT-16 AST-17 ___ 10: 45AM BLOOD ALT-14 AST-15 ___ 10: 45AM BLOOD UricAcd-5.9* <MEDICATIONS ON ADMISSION> - Levemir 22 Qam, 48 Qpm - Nifedipine, 30 mg QD - Aspirin 81 mg QD - Humalog sliding scale with meals - Albuterol PRN <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> Chronic hypertension with superimposed severe preeclampsia Type 1 diabetes Bell's Palsy S/p Cesarean 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 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
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___ G1 with cHTN and T1DM admitted to the antepartum floor at 24w5d with superimposed preeclampsia. She became betamethasone complete on ___. Her 24 hour urine protein resulted at 1108mg. Ms. ___ remained stable on her home dose of nifedipine with normal and mild range blood pressures. On HD23, she was found to have normocytic anemia, with normal Iron studies, B12, folate, bili, coags, and Hgb electrophoresis. At that time she was given folate/B12 and increase in iron supplementation. Patient continued to be stable with normal to mild range BP and intermittent episodes of hypoglycemia through out her admission. She was seen by ___ daily, who adjusted her insulin regimen as necessary. On HD 38, a repeat 24 hour urine protein resulted to 760mg. On ___, she developed an acute onset of a facial droop. Neurology was called and MRI was done which was negative. She was diagnosed with Bell's Palsy and treated with a 7 day course of Prednisone/Valtrex. Lyme serology was negative. She remained clinically stable until 35w5d when she had severe range blood pressures which were unresponsive to IV anti-hypertensives. She was started on Magnesium for neuroprotection and the decision was made to proceed with delivery by cesarean section given her uncontrolled HTN remote from delivery. On ___, she underwent a primary LTCS and delivered a liveborn female weighing 2790 grams with Apgars of 9 and 9. NICU staff was present for delivery and transferred the baby for prematurity. Please see operative report for details. . Ms ___ was continued on Magnesium for 24 hours postpartum. She required one dose of IV Hydralazine postpartum, then was transitioned to po Nifedipine 60mg BID. Her blood pressures were well controlled on this regimen. In regards to her T1DM, her fingersticks were suboptimally controlled (elevated) in the postpartum period. ___ followed her and will have close outpatient follow up. She otherwise had an uncomplicated postop course and was discharged home on POD#4. She will have a blood pressure check in 1 week.
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11052252-DS-22
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Penicillins / Sulfa(Sulfonamide Antibiotics) <ATTENDING> ___ <CHIEF COMPLAINT> pelvic mass <MAJOR SURGICAL OR INVASIVE PROCEDURE> exploratory laparotomy, total abdominal hysterectomy, bilateral salpingo-oopherectomy, omentectomy, appendectomy, optimal debulking, cystoscopy <HISTORY OF PRESENT ILLNESS> This is a ___ gravida 1, para 1 woman who reports a ___ month history of persistent gastrointestinal symptoms. She reports a long history of fatigue, nausea and abdominal discomfort. An abdominal ultrasound was performed on ___. This revealed ascites with an omental mass and peritoneal nodularity concerning for metastatic disease. A paracentesis was performed, which revealed malignant cells consistent with adenocarcinoma. The immunohistochemical profile was positive for CK7 and p53 and negative for CK20, mammaglobin GCDFP-15, ER, PR and WT1. All told, this immuno profile was nonspecific, but favored a gynecologic origin. The imaging studies revealed an irregular right ovary and left ovary with extensive heterogeneous solid tumor surrounding it. Omental disease is also identified. The patient is here for discussion of treatment options. Of note, she does not have a CA-125 level drawn at this point. She is otherwise in relatively good health. <PAST MEDICAL HISTORY> <PAST MEDICAL HISTORY> She does report a history of breast cancer treated in ___. She had surgery, chemotherapy, and radiation therapy. She did receive tamoxifen, which continued through to ___. She has had no evidence of disease recurrence. She does report having had a laparoscopic left sigmoid colectomy with splenic flexure mobilization in ___. She denies any history of asthma, hypertension, cardiac disease, or diabetes. She is up-to-date with mammograms. Past Surgical History: As above. She also had tonsils and adenoids removed. Obstetrics and Gynecologic History: She is a gravida 1, para 1 woman. She denies any history of abnormal Pap smears or pelvic infections. <SOCIAL HISTORY> ___ <FAMILY HISTORY> She reports that her mother had abdominal sarcoma. There is no other family history of a gynecologic or abdominal malignancy. She does report having been tested for BRCA1 and BRCA2 several years ago and those were reportedly negative. <PHYSICAL EXAM> Prior to admission: General: She appears her stated age, in no apparent distress. Neck: Supple. There are no masses. Lymph Node Survey: Negative cervical, supraclavicular, axillary, or inguinal adenopathy. Lungs: Clear. Heart: Regular rate and rhythm. Back: No spinal or CVA tenderness. Abdomen: Soft, nontender, it is distended with a fluid wave. There is no palpable mass appreciated. There is no organomegaly. There is no nodularity at the umbilicus. There is no palpable inguinal adenopathy. Pelvic: Normal external genitalia. Inner labial folds normal. Urethral meatus normal. Walls of the vagina are smooth. Vaginal canal is normal. Bimanual exam reveals nodularity in the posterior cul-de-sac but with a mobile mass extending on the left side, which feels to be consistent with an involved left ovary. The uterus is mobile. There is no parametrial nodularity. On discharge: General: NARD, comfortable, well-appearing CV: RRR Lungs: CTAB Abdomen: Soft, appropriately tender, nondistended, no rebound or guarding Incision: Vertical midline with staples clean, dry, intact Extremities: Nontender <PERTINENT RESULTS> ___ 05: 01PM BLOOD WBC-8.4 RBC-2.89* Hgb-7.5* Hct-23.6* MCV-82 MCH-26.0* MCHC-31.9 RDW-15.8* Plt ___ ___ 02: 30AM BLOOD WBC-9.9 RBC-3.59* Hgb-10.1*# Hct-29.1* MCV-81* MCH-28.0 MCHC-34.6 RDW-15.6* Plt ___ ___ 06: 25AM BLOOD WBC-10.1 RBC-3.60* Hgb-9.9* Hct-29.0* MCV-81* MCH-27.6 MCHC-34.3 RDW-15.7* Plt ___ ___ 08: 15AM BLOOD WBC-5.4 RBC-3.25* Hgb-8.9* Hct-26.5* MCV-82 MCH-27.4 MCHC-33.6 RDW-17.4* Plt ___ ___ 03: 40PM BLOOD WBC-5.9 RBC-3.26* Hgb-8.7* Hct-26.8* MCV-82 MCH-26.6* MCHC-32.4 RDW-17.1* Plt ___ ___ 07: 15AM BLOOD WBC-4.7 RBC-3.03* Hgb-8.3* Hct-25.2* MCV-83 MCH-27.5 MCHC-33.0 RDW-18.2* Plt ___ ___ 08: 20AM BLOOD WBC-3.6* RBC-3.27* Hgb-8.9* Hct-28.1* MCV-86 MCH-27.3 MCHC-31.9 RDW-17.7* Plt ___ ___ 07: 00AM BLOOD WBC-3.1* RBC-3.24* Hgb-8.8* Hct-27.3* MCV-84 MCH-27.1 MCHC-32.2 RDW-18.1* Plt ___ ___ 07: 05AM BLOOD WBC-4.8# RBC-3.35* Hgb-9.0* Hct-28.4* MCV-85 MCH-26.8* MCHC-31.6 RDW-18.2* Plt ___ ___ 05: 01PM BLOOD Glucose-147* UreaN-14 Creat-0.7 Na-142 K-4.7 Cl-113* HCO3-21* AnGap-13 ___ 06: 25AM BLOOD Glucose-140* UreaN-19 Creat-0.8 Na-138 K-4.8 Cl-106 HCO3-25 AnGap-12 ___ 08: 15AM BLOOD Glucose-85 UreaN-10 Creat-0.6 Na-140 K-3.8 Cl-103 HCO3-28 AnGap-13 ___ 07: 15AM BLOOD Glucose-126* UreaN-8 Creat-0.5 Na-139 K-4.2 Cl-105 HCO3-26 AnGap-12 ___ 08: 20AM BLOOD Glucose-124* UreaN-5* Creat-0.5 Na-139 K-4.5 Cl-106 HCO3-28 AnGap-10 ___ 07: 00AM BLOOD Glucose-112* UreaN-4* Creat-0.5 Na-140 K-4.6 Cl-108 HCO3-26 AnGap-11 ___ 07: 05AM BLOOD Glucose-88 UreaN-6 Creat-0.6 Na-139 K-4.6 Cl-105 HCO3-26 AnGap-13 ___ 05: 01PM BLOOD Calcium-10.0 Phos-5.9*# Mg-1.6 ___ 06: 25AM BLOOD Calcium-9.0 Phos-4.9* Mg-1.9 ___ 08: 15AM BLOOD Calcium-8.6 Phos-2.6*# Mg-1.8 Iron-15* ___ 07: 15AM BLOOD Calcium-8.2* Phos-2.8 Mg-1.7 ___ 08: 20AM BLOOD Calcium-8.2* Phos-2.2* Mg-2.1 ___ 07: 00AM BLOOD Calcium-8.3* Phos-2.8 Mg-1.8 ___ 07: 05AM BLOOD Calcium-8.4 Phos-4.1 Mg-2.1 ___ 08: 15AM BLOOD calTIBC-114* ___ TRF-88* ___ 01: 51PM BLOOD Type-ART pO2-181* pCO2-35 pH-7.29* calTCO2-18* Base XS--8 Intubat-INTUBATED Vent-CONTROLLED ___ 01: 51PM BLOOD Glucose-136* Lactate-2.2* Na-137 K-4.7 Cl-109* ___ 01: 51PM BLOOD Hgb-9.0* calcHCT-27 O2 Sat-98 ___ 01: 51PM BLOOD freeCa-0.92* <MEDICATIONS ON ADMISSION> The Preadmission Medication list is accurate and complete. 1. Acetaminophen 325-650 mg PO Q6H: PRN pain <DISCHARGE MEDICATIONS> 1. Ibuprofen 400 mg PO Q8H: PRN pain RX *ibuprofen 400 mg 1 tablet(s) by mouth every eight (8) hours Disp #*60 Tablet Refills: *0 2. Oxycodone-Acetaminophen (5mg-325mg) ___ TAB PO Q4H: PRN pain RX *oxycodone-acetaminophen 5 mg-325 mg ___ tablet(s) by mouth every four (4) hours Disp #*60 Tablet Refills: *0 3. Docusate Sodium 100 mg PO BID RX *docusate sodium 100 mg 1 tablet(s) by mouth twice a day Disp #*60 Capsule Refills: *0 4. Bisacodyl ___AILY: PRN constipation RX *bisacodyl 10 mg 1 Suppository(s) rectally once a day Disp #*30 Suppository Refills: *0 5. Lorazepam 0.25 mg PO Q4H: PRN anxiety RX *lorazepam 0.5 mg 0.5 (One half) tablet by mouth every four (4) hours Disp #*30 Tablet Refills: *0 6. Polyethylene Glycol 17 g PO DAILY: PRN constipation RX *polyethylene glycol 3350 17 gram 1 packet by mouth daily Disp #*30 Packet Refills: *0 <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> pelvic mass <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Dear Ms. ___, You were admitted to the gynecologic oncology service after undergoing the procedures listed below. You have recovered well after your operation, and the team feels that you are safe to be discharged home. Please follow these instructions: * 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. It is ok to use stairs. * Nothing in the vagina (no tampons, no douching, no sex) for 12 weeks. * No heavy lifting of objects >10 lbs for 6 weeks. * You may eat a regular diet. Incision care: * You may shower and allow soapy water to run over incision; no scrubbing of incision. No bath tubs for 6 weeks. * If you have staples, they will be removed at your follow-up visit. * We recommend you use colace twice daily to prevent constipation while taking narcotics (percocet). If you experience loose stools or diarrhea, you can decrease colace to once daily or zero times daily. * Should you experience constipation despite using colace, you may use miralax daily. Should you experience diarrhea, decrease use of the miralax. * Should you experience constipation despite use of miralax, you may use a dulcolax suppository daily. * You may use ativan 0.25-0.5mg as needed for anxiety or for insomnia at night prior to going to sleep. To reach medical records to get the records from this hospitalization sent to your doctor at home, call ___. Call your doctor ___ ___ for: * fever > 100.4 * severe abdominal pain * difficulty urinating * vaginal bleeding requiring >1 pad/hr * abnormal vaginal discharge * redness or drainage from incision * nausea/vomiting where you are unable to keep down fluids/food or your medication * chest pain or difficulty breathing
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Ms. ___ was admitted to the gynecology oncology service after undergoing exploratory laparotomy, total abdominal hysterectomy, bilateral salpingo-oopherectomy, appendectomy, omentectomy, optimal debulking 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 an epidural. She was initially NPO with IV fluids. In the PACU, her hematocrit declined from 27.0 preoperatively to 23.6 despite receiving 2 units of pRBC intraoperatively. She remained hemodynamically stable. She received 2 additional units of pRBCs for blood loss anemia. Her hematocrit increased appropriately to 29.1 and remained stable throughout the remainder of her hospitalization. On postoperative day #2, her epidural was discontinued and she was transitioned to a dilaudid PCA, IV tylenol and IV toardol. Her diet was advanced to sips and then to clears. On postoperative day #3, her urine output was adequate so her Foley catheter was removed and she voided spontaneously. On postoperative day #5, her diet was advanced to toast and crackers and then to a regular diet. She was transitioned to oral percocet and ibuprofen for pain control. She received lovenox throughout her hospitalization for venous thromboembolism prevention. By post-operative day #6, she was tolerating a regular diet, voiding spontaneously, ambulating independently, and pain was controlled with oral medications. She was then discharged home in stable condition with outpatient follow-up scheduled.
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