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11052692-DS-2
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___ <CHIEF COMPLAINT> Abdominal pain (Complex adnexal mass,irregular endometrium) <MAJOR SURGICAL OR INVASIVE PROCEDURE> Exploratory laparoscopy, exploratory laparotomy, Radical hysterectomy, Bilateral salpingo-oophorectomy, Radical resection of a pelvic tumor, Repair of incidental cystotomy, Cystoscopy, Rigid sigmoidoscopy, Infracolic omentectomy, optimal cytoreductive surgery. <HISTORY OF PRESENT ILLNESS> ___ year old ___ female who initially presented with abdominopelvic discomfort in ___. A CT scan revealed a cystic left adnexal mass. A right adnexal mass had previously been identified, and it was thought that this was a dermoid. The uterus had evidence of a fibroid but was otherwise normal. Ms. ___ reports having an experience of postmenopausal bleeding. She had a followup pelvic ultrasound that revealed that the right adnexal mass was now solid, measuring 5.8 x 2.3 x2.7 cm with vascularity. The left ovary now had a complex cyst,but this was actually less visibly different than three months prior. Interestingly, the endometrium was notably thicker at 8mm. Because of the concern for the possibility of malignancy plans were made to proceed for an operative evaluation. <PAST MEDICAL HISTORY> PAST MEDICAL HISTORY: HTN, venous insufficiency, irritable bowel syndrome, osteoporosis, spinal stenosis HEALTH MAINTENANCE: She reports being up-to-date with mammograms and bone density evaluations. She has never had a colonoscopy. PAST SURGICAL HISTORY: In ___, she had a knee replacement at the ___ without complication. OB/GYN HISTORY: She is a gravida 0 woman. She reports her last menstrual cycle was ___ years ago. She denies any history of pelvic infections. <SOCIAL HISTORY> ___ <FAMILY HISTORY> Non contributory <PHYSICAL EXAM> Pre-Operative <PHYSICAL EXAM> GENERAL: She appears her stated age, in no apparent distress. NECK: Supple, no masses. LYMPHATICS: Lymph node survey, negative cervical, supraclavicular, axillary, or inguinal adenopathy. CHEST: Lungs clear. HEART: Regular rate and rhythm. BACK: No spinal or costovertebral angle tenderness. ABDOMEN: Soft, nontender, nondistended. There are no masses. EXTREMITIES: There is no clubbing, cyanosis, or edema. There is no calf tenderness to palpation. PELVIC: Normal external genitalia. Inner labial folds normal. Urethral meatus is normal.Walls of the vagina are smooth. Cervix is normal. Bimanual exam reveals a mobile but irregularly contoured uterus. There is no palpable nodularity in the posterior cul-de-sac. There is a fullness noted to the right side. RECTAL: Reveals no mass or lesion. PHYSICAL EXAM ON DISCHARGE: Vital signs stable GENERAL: no apparent distress CHEST: Lungs clear to auscultation bilaterally, no wheezes/crackles HEART: Regular rate and rhythm. ABDOMEN: Soft, nondistended, appropriate tenderness to palpation, +bowel sounds, no rebound/guarding. Superficial skin ulceration close to JP drain tubing. No erythema or induration at JP site. Incision clean/dry/intact, staples in place. EXTREMITIES: Non tender, non edematous <PERTINENT RESULTS> CBC: ___ 07: 40AM BLOOD WBC-8.6 RBC-3.61* Hgb-11.1* Hct-31.7* MCV-88 MCH-30.9 MCHC-35.1* RDW-13.4 Plt ___ ___ 06: 15AM BLOOD WBC-4.5 RBC-3.21* Hgb-9.6* Hct-28.2* MCV-88 MCH-30.0 MCHC-34.1 RDW-13.8 Plt ___ ___ 06: 30AM BLOOD WBC-6.3 RBC-3.55* Hgb-10.8* Hct-31.0* MCV-88 MCH-30.5 MCHC-34.8 RDW-13.8 Plt ___ ___ 07: 40AM BLOOD Neuts-84.9* Lymphs-9.6* Monos-5.1 Eos-0.2 Baso-0.3 ___ 06: 40AM BLOOD Neuts-75.0* ___ Monos-3.9 Eos-2.1 Baso-0.4 ___ 06: 15AM BLOOD Neuts-66.2 ___ Monos-5.7 Eos-2.9 Baso-0.5 ___ 06: 30AM BLOOD WBC-6.3 RBC-3.55* Hgb-10.8* Hct-31.0* MCV-88 MCH-30.5 MCHC-34.8 RDW-13.8 Plt ___ ___ 06: 15AM BLOOD WBC-7.1 RBC-3.96* Hgb-11.8* Hct-34.9* MCV-88 MCH-29.9 MCHC-33.9 RDW-14.0 Plt ___ Chem-10: ___ 07: 40AM BLOOD Glucose-133* UreaN-8 Creat-0.6 Na-141 K-4.0 Cl-109* HCO3-28 AnGap-8 ___ 06: 15AM BLOOD Glucose-89 UreaN-5* Creat-0.5 Na-140 K-3.7 Cl-106 HCO3-27 AnGap-11 ___ 08: 15AM BLOOD Glucose-94 UreaN-7 Creat-0.6 Na-137 K-4.2 Cl-105 HCO3-28 AnGap-8 ___ 07: 40AM BLOOD Calcium-8.0* Phos-2.8 Mg-1.9 ___ 06: 15AM BLOOD Calcium-7.5* Phos-2.5* Mg-2.0 ___ 08: 15AM BLOOD Calcium-8.5 Phos-3.3 Mg-2.2 ___ 06: 30AM BLOOD Glucose-98 UreaN-12 Creat-0.7 Na-139 K-3.9 Cl-103 HCO3-29 AnGap-11 ___ 06: 15AM BLOOD Glucose-100 UreaN-16 Creat-0.8 Na-138 K-4.3 Cl-100 HCO3-30 AnGap-12 <MEDICATIONS ON ADMISSION> ALENDRONATE - 70 mg Tablet - 1 Tablet(s) by mouth weekly ATENOLOL - 25 mg Tablet - 1 Tablet(s) by mouth qAM BUPROPION HCL - 150 mg Tablet Extended Release 24 hr - 1 Tablet(s) by mouth daily CELECOXIB [CELEBREX] - (On Hold from ___ to unknown for started Vicoprofen.) - 100 mg Capsule - 1 Capsule(s) by mouth twice a day DIAZEPAM - 10 mg Tablet - 1 Tablet(s) by mouth every eight (8) hours DIPHENOXYLATE-ATROPINE - 2.5 mg-0.025 mg Tablet - 2 Tablet(s) by mouth daily as needed for diarrhea FUROSEMIDE - 20 mg Tablet - 2 Tablet(s) by mouth daily OXYCODONE - 5 mg Tablet - ___ Tablet(s) by mouth every six (6) hours as needed for back pain PHENOBARB-HYOSCY-ATROPINE-SCOP - 16.2 mg-0.1037 mg-0.0194 mg-0.0065 mg Tablet - 1 Tablet(s) by mouth four times a day as needed for abdominal pain SPIRONOLACTONE - 25 mg Tablet - 1 Tablet(s) by mouth Daily TRAZODONE - 150 mg Tablet - 1 Tablet(s) by mouth at bedtime <DISCHARGE MEDICATIONS> 1. acetaminophen 325 mg Tablet Sig: ___ Tablets PO Q6H (every 6 hours) as needed for pain: Do not exceed 4000 mg acetaminophen within 24 hours. Disp: *50 Tablet(s)* Refills: *0* 2. hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. Disp: *40 Tablet(s)* Refills: *0* 3. atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation. Disp: *40 Capsule(s)* Refills: *0* 5. diazepam 10 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed for anxiety. 6. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. Disp: *30 Tablet(s)* Refills: *0* 7. furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. bupropion HCl 150 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release PO QAM (once a day (in the morning)). <DISCHARGE DISPOSITION> Extended Care Facility: ___ <DISCHARGE DIAGNOSIS> Locally advanced ovarian cancer <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Ms. ___, you were admitted for post operative management after undergoing surgery for locally advanced ovarian cancer. 1) Please continue your home medications 2) You will be going to a skilled nursing facility temporarily. 3) Foley catheter to be removed by Dr. ___ in clinic on ___. 4) The nursing facility will remove your staples on ___. 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 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. * Your staples should be removed by the skilled nursing facility on ___.
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Ms. ___ is an ___ year old female who was admitted to ___ and underwent exploratory laparoscopy,exploratory laparotomy, radical hysterectomy,bilateral salpingo-oophorectomy, radical resection of a pelvic tumor, repair of incidental cystotomy, cystoscopy, rigid sigmoidoscopy, infracolic omentectomy, optimal cytoreductive surgery on ___. Please see the operative report for full details of the procedure. She was admitted to the Gyn Oncology service for post operative management. *) Routine Post-Op: Initially Ms. ___ pain was controlled with a Dilaudid PCA. She was transitioned to oral pain medication once tolerating a diet. Her pain remained well controlled. Her diet was advanced slowly but without difficulty to a regular diet on post operative day #4. Due to intraoperative cystotomy repair, a foley catheter was placed and will remain in place for 2 weeks post operatively. A JP drain was also placed in the right upper quadrant prior to closure because of the cystotomy. This was removed prior to discharge. Her urine output was adequate throughout inpatient stay. *) Hypertension: Ms. ___ home dose of atenolol was continued throughout her stay. Her blood pressures were stable throughout. *) Anxiety/Depression: Ms. ___ was given IV diazepam while NPO and was transitioned to PO diazepam as she tolerated a diet. Her home buproprion was resumed prior to discharge. Social was consulted during her stay to assist in coping with diagnosis. Additionally, there were initial concerns regarding the patient's adopted son and possible elder abuse. An elder abuse/neglect report was filed with Ethos, although Ms. ___ declined intervention. Ethos will not mandate that the son leave the home, but rather, can offer services and counseling to help Ms. ___ have her needs met. *) Wound care: During her stay, Ms. ___ was noted to have a superficial skin ulceration in left lower quadrant of abdomen, likely related to abrasion from JP drain tubing. Also, Ms. ___ developed superficial skin irritation near her peripheral IV site on her right arm which was dressed with Kerlix and Aquacel daily. her JP drain site in the right lower quadrant was noted to be healing well on day of discharge. Ms. ___ was discharged to a skilled nursing facility in stable condition on post operative day 8.
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| 495
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11053422-DS-15
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Flagyl <ATTENDING> ___. <CHIEF COMPLAINT> Proteinuria <MAJOR SURGICAL OR INVASIVE PROCEDURE> s/p Primary LTCS <HISTORY OF PRESENT ILLNESS> ___ G3P0 at ___ presents after results of a 24H urine returned revealing 1428mg of protein. Patient has baseline protienuria first noted at age ___ during pre-operative screening for a CCY. The patient had a baseline 24hour collected ___ which was significant for a total protein of 410mg. She has never had glomerulonephritis or other renal disease. An autoimmune etiology was entertained by her PCP though ___ factor, ___, anti-dsDNA, and ___ antibody testing was negative. Dr. ___, saw her ___ and found her renal status to be stable and that she had a small amount of microalbinuria present and no obvious evidence of renal disease. Patient was seen in ob triage on ___ with headache, visual changes, and upper and lower extremity swelling. She had PEC labs checked which were notable for Pr/Cr of 0.5 with the rest of her labs WNL. Her blood pressures were all normal. The patient was sent home to collect a 24hour urine. The results of this are noted above. Currently the patient reports that she does have some spots in her vision, similar to floaters, which have been present for approx 2 weeks. She denies any HA/Abd pain. She denies any LOF/VB. She endorses active fetal movement. <PAST MEDICAL HISTORY> PNC: ___ ___ A+/Ab neg/RI/RPR NR/HepBsAg neg/GBS ___ Low Risk ERA, nl FFS GLT 111 Hx of marijuana use in pregnancy - pt denies any recent use, verbally consented for urine tox screen OBHx: TABx2 PMHx: Proteinuria of unclear etiology, Depression PSHx: D&Cx2, LSC CCY <SOCIAL HISTORY> ___ <FAMILY HISTORY> NC <PHYSICAL EXAM> On arrival: 98.4 84 20 126/73 BPs 132/91, 115/91, 122/67, 120/78 NAD RRR CTAB ABD: soft, gravid, NT EXT: +2 edema up to knee, DTRs ___ <PERTINENT RESULTS> ___ 02: 12PM URIC ACID-5.2 ___ 02: 12PM ALT(SGPT)-16 AST(SGOT)-22 ___ 02: 12PM URINE HOURS-RANDOM CREAT-50 TOT PROT-78 PROT/CREA-1.6* ___ 02: 12PM ___ PTT-25.2 ___ ___ 02: 12PM URINE BLOOD-TR NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 LEUK-NEG <MEDICATIONS ON ADMISSION> PNV <DISCHARGE MEDICATIONS> 1. breast pump baby in NICU 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. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for Pain. Disp: *60 Tablet(s)* Refills: *0* 4. Oxycodone-Acetaminophen ___ mg Tablet Sig: ___ Tablets PO every ___ hours as needed for Pain. Disp: *30 Tablet(s)* Refills: *0* <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> Severe Preeclampsia Primary LTCS at 34 wks <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> See discharge instruction sheet
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The patient is a ___ year old gravida 3 para 0 who was admitted to the antepartum service for expectant management of pre-eclampsia in the setting of baseline proteinuria. . *) Pre-Eclampsia: The patient initially complained of floaters in her vision on arrival. These resolved spontaneously. She also had intermittent mild headaches which were relieved by Tylenol. She never had any epigastric pain. Her blood pressures were mostly within normal limits. She had a few blood pressures with systolics at 140 or diastolics up to 90. Her labs were checked twice per week and were only notable for a mildly elevated uric acid which peaked at 6.2 and a 24hour urine done on ___ which was 1428mg. The patient was evaluated by ___ and renal while in house. ___ felt that the patient was suffering from superimposed pre-eclampsia. Renal agreed with this. The patient was made BMZ complete by ___. She was seen by the NICU. She had several ultrasounds done. She had an EFW on ___ which was 1430g, ___ percentile and on ___ which was 1591g, ___. On ___ a repeat ___ was noted to be greater than 6 grams of protein and she had a persistent headache. The decision was made to proceed with delivery given the worsening pre-eclampsia and the fact that she was Betamethasone complete. The options for delivery were discussed and pt elected to proceed to cesarean delivery. She had an uncomplicated low transverse cesarean section on ___. *) Postpartum her blood pressures were well controlled at goal without antihypertensives. She received magnesium for 24 hours postpartum for seizure prophylaxis. She remained without symptoms of pre-eclampsia except for an occasional mild headache which resolved with sleep and Tylenol. Her HEELP labs remained normal and her uric acid trended down to 5.9. Of note, the patient had a remote history of marijuana use early in the pregnancy. She had a negative utox on admission.
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11055169-DS-21
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> contractions, bleeding <MAJOR SURGICAL OR INVASIVE PROCEDURE> dilation and evacuation interuterine foley catheter <HISTORY OF PRESENT ILLNESS> ___ yo G5 P3 at ___ transferred from ED for painful contractions q2min and vaginal bleeding since 1 night prior. Reports started having light vaginal bleeding last night, and began to have painful contractions today every 2 minutes. Patient was late presentation of care, and dating by ___ trimester ultrasound. On FFS noted to have fused anterior frontal horns with possible septo-optic dysplasia. Was to follow up with ___ for MRI however patient missed appointment, not yet rescheduled. <PAST MEDICAL HISTORY> PNC: *) Dating: ___: ___ by ___ trimester ultrasound *) Labs: O+ /Ab neg /RPRNR/RI/HbsAg neg/HIV neg/ *) Routine: - U/S: abnormalities as above, no evidence of previa - Genetics: low risk NIPT *) Issues: - late presentation at 20wks - marijuana positive on urine tox at initial prenatal POBHx: - G1- SVD term ___ - G2- SAB ___ - G3- SVD term ___ - G4- CS term ___ for NRFHT PGynHx: Denies STDs or abnl paps PMH: Anxiety, PSH: CS x1 Meds: PNV All: NKDA <SOCIAL HISTORY> ___ <FAMILY HISTORY> Noncontributory <PHYSICAL EXAM> On admission: PE: HR 105 BP 119/65 NAD CTA bilaterally RRR Abd soft, gravid, NT SSE: no active bleeding, cervix dilated bulging membranes SVE: RIM/ BBOW FHR: 110-120 on spot check Toco: q2-4min On day of discharge: afebrile, VSS Gen: NAD Pulm: normal work of breathing Abd: soft, nontender <PERTINENT RESULTS> ___ 11: 30PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG cocaine-NEG amphetmn-NEG mthdone-NEG ___ 08: 45PM WBC-10.7# RBC-3.69* HGB-11.1* HCT-31.8* MCV-86# MCH-30.1 MCHC-34.9 RDW-13.3 ___ 11: 30PM URINE RBC-1 WBC-6* BACTERIA-NONE YEAST-NONE EPI-2 <MEDICATIONS ON ADMISSION> PNV <DISCHARGE MEDICATIONS> tylenol prn <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> previable intrauterine fetal demise with placental abruption <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 ___-fetal medicine service following fetal demise with placental abruption requiring dilation and evacuation of uterine contents, which was complicated by continued bleeding requiring blood products and several interventions to control your bleeding. You have since been doing well and your doctors feel ___ are safe to go home with outpatient followup. Please follow these instructions: - nothing in the vagina (no tampons, no douching, no sex) until after your bleeding has stopped - you may resume normal activities upon going home
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Ms. ___ was admitted to the postpartum service after presenting in preterm labor at 22w5d with subsequent fetal demise and need for dilation and evacuation. Her postpartum course was complicated by several episodes of hemorrhage totalling 2700cc, for which she received a total of 3 units of reb blood cells, 3 units of FFP and 2 units of cryoprecipitate. She also had an intrauterine foley catheter placed on hospital day 2 with subsequent hemostasis. Her intrauterine foley was removed after several hours of hemostasis. Her urine output was adequate so her foley catheter was removed on hospital day 3 but was replaced after several hours due to inability to empty her bladder. On hospital day 4 her urine output remained adequate so her foley catheter was removed and she voided spontaneously. On hospital day 4 she was tolerating a regular diet, voiding spontaneously, had minimal lochia and stable labs and she was discharged home in good condition with outpatient followup.
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11055169-DS-22
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___ <CHIEF COMPLAINT> Gestational Hypertension <MAJOR SURGICAL OR INVASIVE PROCEDURE> Low transverse cesarean section <HISTORY OF PRESENT ILLNESS> Ms. ___ is a G5P3 who presents for induction of labor for gestational hypertension and post-dates at 40w4d. She had a negative pregnancy in hypertension eval on ___ but has continued to have elevated BPs. She has a hx of tobacco use, and EFW is in the ___ %ile. In the office on ___ she was 1/long/-2. At that time she denied headache, vaginal bleeding, loss of fluid, and contractions. <PAST MEDICAL HISTORY> Prenatal care: - late initiation of care at 21 weeks, normal prenatal labs - FFS normal. GLT negative. - Pt taking iron for anemia. -___ U/S ___ EFW 22%ile, AC 19%. -Hx substance use during pregnancy: patient reports ETOH and Marijuana use earlier in pregnancy, she denies current use of either. Tox screen + for marijuana only at past visits. OBHx: G6P3 -___ VBAC @ 22 wks (preterm labor, demise) -___ c/s @ term -SVDx2 @ term PMH: Anxiety/Depression Meds: PNV All: NKDA <SOCIAL HISTORY> ___ <FAMILY HISTORY> Noncontributory <PHYSICAL EXAM> BP 121/76 HR 88 RR 16 Cardio: nl pulse Breasts: deferred Lungs: nl respiration Uterus S<D Last SVE: ___ <PERTINENT RESULTS> ___ 12: 25PM CREAT-0.6 ___ 12: 25PM ALT(SGPT)-18 AST(SGOT)-21 ___ 12: 25PM URINE HOURS-RANDOM CREAT-211 TOT PROT-27 PROT/CREA-0.1 ___ 10: 18AM WBC-7.8 RBC-3.75* HGB-10.4* HCT-31.9* MCV-85 MCH-27.7 MCHC-32.6 RDW-15.4 RDWSD-46.8* ___ 10: 18AM PLT COUNT-208 <MEDICATIONS ON ADMISSION> Iron, PNV <DISCHARGE MEDICATIONS> 1. Ibuprofen 600 mg PO Q6H Pain RX *ibuprofen 600 mg 1 tablet(s) by mouth every six (6) hours Disp #*40 Tablet Refills: *0 2. Docusate Sodium 100 mg PO BID Constipation RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day Disp #*60 Capsule Refills: *0 3. Acetaminophen 1000 mg PO Q6H Pain 4. Nicotine Patch 14 mg TD DAILY RX *nicotine 14 mg/24 hour Apply 1 patch once a day Disp #*28 Patch Refills: *0 5. NIFEdipine CR 30 mg PO DAILY RX *nifedipine 30 mg 1 tablet(s) by mouth once a day Disp #*30 Tablet Refills: *1 6. QUEtiapine Fumarate 200 mg PO BID RX *quetiapine 200 mg 1 tablet(s) by mouth twice a day Disp #*30 Tablet Refills: *0 7. Prochlorperazine 10 mg PO Q6H: PRN nausea RX *prochlorperazine maleate [Compazine] 5 mg 1 tablet(s) by mouth every six (6) hours Disp #*15 Tablet Refills: *0 <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> cesarean delivery gestational hypertension Ileus post-operative <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Routine postpartum instructions
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Ms. ___ is a ___ s/p low transverse cesarean section after a failed induction of labor for gestational hypertension. Her hospital course was complicated by post-op ileus. *)Labor: When pt presented for induction, she received an epidural and was AROM'd (light meconium). She was placed on pitocin per protocol for labor induction. Pt was GBS positive and PCN was given. She underwent a stat repeat low transverse c-section for category II fetal heart tracing (recurrent deep variables + late decels), during which she received 1500cc IVF, EBL 600cc. *)Ileus: On PPD 1 she developed RUQ/epigastric pain with eating, and on PPD5 she began to have nausea and vomiting, which was treated w/ IV fluids and IV zofran. Her abdomen was noted to be increasingly distended with concern for ileus. KUB revealed multiple distended loops of small bowel with distension. She was made NPO and she stopped taking narcotics. Her diet was slowly advanced. Her symptoms improved, however pt was eager to leave even though her symptoms had not completely resolved, she left for a court hearing. *)gHTN: Pt had mild range BP during her hospital stay, and was initially on Nifedipine 10mg PO. On PPD8 she developed severe range pressures and she was started on Nifedipine 30mg CR. Her preeclampsia labs remained within normal limits during her stay. *)Pt was continued on seroquel 200mg daily for her history of depression and anxiety. She was seen by social work during her admission for depression, anxiety, substance abuse, as well as issues involving DCF.
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11063215-DS-10
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> amoxicillin-pot clavulanate <ATTENDING> ___. <CHIEF COMPLAINT> Respiratory distress <MAJOR SURGICAL OR INVASIVE PROCEDURE> Debridement of left vulvar abscess with placement of word catheter. <HISTORY OF PRESENT ILLNESS> The patient is a ___ year old female with minimal past medical history who was admitted to Gynecology for surgical management of a Bartholin gland abscess. She was transferred to the ICU for acute onset of hypoxemic respiratory failure this morning. She first developed symptoms about 1 week ago with fevers and flu like symptoms. Over the course of the week she continued to have intermittent fevers, and developed pain and swelling in the left vulva with scant purulent drainage. Her temperature reached a peak of 103.7 at home on ___. She was seen at ___ on ___, with an initial diagnosis of Barthoin gland cyst. Her symptoms worsened and she was seen on ___ by a different provider who diagnosed chancroid and prescribed Azithromycin 1000 mg. She read about this diagnosis online, and felt that this was unlikely since she lacked risk factors. On ___, she presented to the ED where she was afebrile but tachycardic. She was diagnosed with a left Bartholin's abscess. An I&D was performed, but a Word catheter could not be placed. A wick was placed instead, but fell out shortly after. She was prescribed a course of Bactrim. She presented for urgent followup in Gynecology clinic the next day on ___ with fevers, diaphoresis, tachycardia, and continued pain and fluctuance in the area of the abscess. She was admitted to Gynecology for operative management. <PAST MEDICAL HISTORY> # Headaches -- bifrontotemporal preasure -- unclear diagnosis of migraines -- reported amaurosis fugax, memory problems, and paraphasic errors -- normal neuro exam (___), CT (___) and MRI (___) # Arthralgias -- unrevealing Rheumatology workup (___) # G1P1 with uncomplicated SVD # Bartholin Gland Abscess -- ED visit (___) <SOCIAL HISTORY> ___ <FAMILY HISTORY> No history of difficulty with anesthesia or complications of surgery. No history of DVT or PE. Multiple family members with diabetes and hypercholesterolemia. <PHYSICAL EXAM> On admission: T 100.7, HR 120, BP 90/56 Gen: diaphorectic, wincing in pain CV: tachycardic, regular rhythm Resp: CTAB Abd: soft, NT/ND no rebound or guarding Bedside U/S: 3.5 cm fluctuant mass in area of Bartholin's at 5 o'clock just proximal to fourchette on left. Exam limited by discomfort, tracks 2 cm along alteral vaginal wall. Exquisitely TTP, draining scant purulent discharge with surrounding erythema. 0.5cm I&D site distal to hart's line. +inguinal LAD On admission to ICU: General: Young female in no acute distress, but appears uncomfortable. Alert and oriented. HEENT: Sclera anicteric, EOMI, PERRL. MMM, oropharynx without erythema or lesions. Neck: JVP not elevated. No significant cervical or supraclavicular lymphadenopathy. CV: Regular tachycardia, normal S1 and S2. No murmurs, rubs, or gallops Lungs: Bibasilar crackles, some fine and some coarse, few rhonchi. No significant wheezing. Abdomen: Bowel sounds present. Soft, non-distended. Tender to palpation in RUQ with negative ___ sign. No guarding or tap tenderness. No organomegaly. GU: No foley. Left labia markedly swollen and tender, word catheter in place at inferior aspect. Erythema limited to labia without extension. Ext: Warm and well perfused. Pulses 2+ distally. No lower extremity edema. Skin: No visible rash. Neuro: CN II-XII intact, moving all limbs. -= On discharge: Gen: NAD CV: RRR Lungs: CTAB Abd: soft, NT, non-distended Labia: <PERTINENT RESULTS> LABS: On admission: ___ 12: 55PM BLOOD WBC-6.5 RBC-4.15* Hgb-11.9* Hct-34.9* Plt ___ Neuts-66.0 ___ Monos-7.4 Eos-0.1 Baso-0.3 ___ PTT-30.4 ___ Glucose-100 UreaN-5* Creat-0.8 Na-137 K-3.7 Cl-103 HCO3-26 AnGap-12 F/u LABS ___ 05: 15AM WBC-7.2 RBC-3.69* Hgb-10.5* Hct-31.7* Plt ___ Neuts-72.9* ___ Monos-3.3 Eos-0.5 Baso-0.5 ___ 06: 32AM BLOOD Type-ART Temp-36.7 pO2-61* pCO2-33* pH-7.51* calTCO2-27 Base XS-3 Intubat-NOT INTUBA Comment-SIMPLE FAC ___ 11: 51AM BLOOD Lactate-1.7 ___ 11: 30AM BLOOD ___ PTT-34.4 ___ ___ ALT-25 AST-31 LD(LDH)-232 AlkPhos-66 TotBili-0.5 ___ 04: 35AM Glucose-113* UreaN-6 Creat-0.5 Na-135 K-4.2 Cl-103 HCO3-25 AnGap-11 ___ 09: 00AM WBC-6.4 RBC-3.98* Hgb-11.3* Hct-33.7* Plt ___ Neuts-70.4* ___ Monos-5.8 Eos-4.2* Baso-0.5 ___ HBsAg-NEGATIVE, HIV Ab-NEGATIVE, HCV Ab-NEGATIVE; RPR non-reactive MICROBIOLOGY ___ 4: 59 pm SWAB NEISSERIA GONORRHOEAE (___), NUCLEIC ACID PROBE, WITH AMPLIFICATION (Final ___: Negative for Neisseria Gonorrhoeae by PCR. Chlamydia trachomatis, Nucleic Acid Probe, with Amplification (Final ___: Negative for Chlamydia trachomatis by PCR. ___ 4: 21 pm SWAB LABIAL. GRAM STAIN (Final ___: 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. 3+ ___ per 1000X FIELD): GRAM POSITIVE ROD(S). WOUND CULTURE (Final ___: This culture contains mixed bacterial types (>=3) so an abbreviated workup is performed. Any growth of P.aeruginosa, S.aureus and beta hemolytic streptococci will be reported. IF THESE BACTERIA ARE NOT REPORTED BELOW, THEY ARE NOT PRESENT in this culture.. Work-up of organism(s) listed below discontinued (excepted screened organisms) due to the presence of mixed bacterial flora detected after further incubation. ENTEROCOCCUS SP.. SPARSE GROWTH. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ENTEROCOCCUS SP. | AMPICILLIN------------ <=2 S PENICILLIN G---------- 2 S VANCOMYCIN------------ 2 S ANAEROBIC CULTURE (Final ___: ANAEROBIC GRAM POSITIVE ROD(S). SPARSE GROWTH. UNABLE TO IDENTIFY FURTHER. RADIOLOGY/DIAGNOSTIC STUDIES: # EKG ___ at 05: 44): Sinus tachycardia at 122 bpm, normal axis and intervals, isolated TWI in III, no ischemic ST changes. # CHEST (PORTABLE AP) ___ at 5: 49 AM): Multifocal opacities, worst in the right mid and lower lung zones. Consider pneumonia or aspiration given recent history of intubation. There is no definite vascular engorgement and upper lobe redistribution; although a background of mild, if any, edema is a possibility. # CTA (___) 1. There is no pulmonary embolism and no acute aortic syndrome. 2. Bilateral clustered area of bronchiolar opacities, airways thickening and focal consolidation are compatible either with a superimposed infection or aspiration. 3. Mild volume overload. # CHEST (PORTABLE AP): There has been improved aeration of the airspace opacities throughout the lower lobes. Heart size is within normal limits. There are no pneumothoraces or signs for overt pulmonary edema. Bony structures are normal. # VULVAR ULTRASOUND (___): Word catheter present within the left mid labia without residual fluid collection visualized. PATHOLOGY: Left vulva, cystectomy: Fragments of necrotic tissue with abscess formation. <MEDICATIONS ON ADMISSION> tylenol bactrim <DISCHARGE MEDICATIONS> 1. Docusate Sodium 100 mg PO BID: PRN constipation RX *docusate sodium 100 mg 1 tablet(s) by mouth twice a day Disp #*60 Capsule Refills: *2 2. Ibuprofen 600 mg PO Q6H: PRN pain RX *ibuprofen 600 mg 1 tablet(s) by mouth every six (6) hours Disp #*60 Tablet Refills: *1 3. OxycoDONE (Immediate Release) ___ mg PO Q3H: PRN pain RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours Disp #*60 Tablet Refills: *0 4. Amoxicillin-Clavulanic Acid ___ mg PO Q12H RX *amoxicillin-pot clavulanate 875 mg-125 mg 1 tablet by mouth every twelve (12) hours Disp #*20 Tablet Refills: *0 <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> Bartholin's abscess <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> General instructions: * Continue ___ baths three times per day * Take your medications as prescribed. * Do not drive while taking narcotics. * Take a stool softener such as colace while taking narcotics to prevent constipation * Do not combine narcotic and sedative medications or alcohol * Do not take more than 4000mg acetaminophen (APAP) in 24 hrs * No strenuous activity until your post-op appointment * You may eat a regular diet 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 To reach medical records to get the records from this hospitalization sent to your doctor at home, call ___.
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___ year old female with minimal past medical history was admitted to Gynecology for IV antibiotics and surgical management of a Bartholin gland abscess. She was taken to the OR on ___, where she had debridement of a left vulvar abscess and placement of Word catheter. There were no immediate surgical complications. Gentamicin and Clindamycin were started after the procedure. She received IV fluids 1600 ml during the case and maintenance fluids afterwards. She had difficulty sleeping on night of post-operative day 0 due to pain and itching. She reports that the itching started around 1 AM and was all over without visible rash. She had received Gentamicin and Clindamycin in the afternoon and again around 11PM. She was also receiving Dilaudid and Percocet for pain control. She was given Diphenhydramine for the itching, with little improvement On post-operative day 1, she woke to use the bathroom around 5AM and had difficulty breathing. She was found to have SpO2 in the ___ on RA, increasing to the low ___ on 7L facemask. Exam showed increased work of breathing, bibasilar crackles, and faint end expiratory wheezes. She was only able to talk in shortened sentences. She was given Ipratropium/Albuterol nebs with subjective improvement. Her CXR showed multifocal opacities, worst in the right mid and lower lung zones. Her ABG was ___ on 7L facemask. She was weaned down to 4L NC with SpO2 in the low ___. She was transferred to the FICU for acute onset of hypoxemic respiratory failure, likely early ARDS in setting of sepsis from vulvar abscess. The remainder of her hospital course is as follows: # Hypoxic Respiratory Failure: Acutely desatted to ___ on RA with multifocal opacities on CXR, transferred to ICU on hospital day 2, post-operative day 1. This was likely early ARDS in setting of sepsis from vulvar abscess vs aspiration PNA. CTA was done and ruled out PE. While in the ICU she was requiring less NC and CXR started improving. She was thus called out of the ICU on hospital day 3, post-operative day 2 (___). On arrival to GYN floor, her oxygen saturations were normal on room air and she denied any shortness of breath. She had no further episodes of oxygen desaturation or shortness of breath by the time of discharge. # Sepsis: Pt met SIRS criteria with fever, sinus tachycardia, tachypnea, and had an infectious source with vulvar abscess. Her tachycardia was fluid responsive on the floor, but she continued to require volume support in form of fluids in the ICU. She had been started on IV gentamicin and clindamycin initially, but given concern for hypoxic respiratory failure and possibility of pneumonia, her antibiotics were changed to IV vancomycin, flagyl, and levofloxacin. Her last fever was on hospital day 3 (___) at 0800 with T max 102, from which she promptly defervesced. Wound culture from vulva grew ENTEROCOCCUS sensitive to vanc, ampicillin, and penicillin, and thus antibiotics were changed to unasyn on hospital day 4, post-operative day 3. Her blood cultures remained negative for bacteria by time of discharge, and she was started on augmentin upon discharge. # Vulvar Abscess: She had operative debridement with Word catheter placement on ___. The left labia remained quite swollen and tender on hospital day 3, post-operative day 2, and given concern for sepsis, a vulvar ultrasound was performed to investigate need for additional debridement, but there was no collection. Her vulvar exam continued to improve with decreased tenderness and decreased swelling. By hospital day 5, post-operative day 4, her vulva remained slightly tender, but there was no induration. She was discharged home with plan for close follow-up as outpatient. # Diffuse Pruritus: Started on post-operative day 0 per patient with no visible rash. Felt to likely be from opioid pain medications. No eosinophilia on labs. Was given Diphenhydramine and Sarna with good effect. # RUQ Tenderness: She had mild RUQ tenderness to palpation on exam with negative ___ sign. LFTs wnl. This resolved by hospital day 4. By hospital day 5, post-operative day 4, the patient had been afebrile for 48 hours and her vulvar exam had much improved. She was thus discharged on oral antibiotics with plan for close outpatient follow-up. Of note, she was also tested for STDs, the results of which were negative.
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11064667-DS-14
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Bactrim <ATTENDING> ___ <CHIEF COMPLAINT> gallstones <MAJOR SURGICAL OR INVASIVE PROCEDURE> s/p laparoscopic cholecystectomy <PHYSICAL EXAM> PHYSICAL EXAM AT DISCHARGE -======= Vitals: 24 HR Data (last updated ___ @ 430) Temp: 98.3 (Tm 98.3), BP: 95/56 (78-105/42-61), HR: 77 (68-77), RR: 18, O2 sat: 99% (97-100), FHR: 140's (130-158) Fluid Balance (last updated ___ @ 1847) Last 8 hours No data found Last 24 hours Total cumulative 873ml IN: Total 1373ml, PO Amt 180ml, IV Amt Infused 1193ml OUT: Total 500ml, Urine Amt 500ml Physical exam: Gen: NAD Card: RRR Pulm: non-labored breathing, no respiratory distress, satting adequately on RA Abd: Soft, non-tender, mildly firm abd distention c/w gravid uterus Wounds: c/d/i <PERTINENT RESULTS> ___ 08: 35PM URINE COLOR-Yellow APPEAR-Hazy* SP ___ ___ 08: 35PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR* GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 LEUK-NEG ___ 08: 35PM URINE RBC-0 WBC-0 BACTERIA-FEW* YEAST-NONE EPI-2 TRANS EPI-<1 ___ 08: 35PM URINE AMORPH-OCC* ___ 08: 35PM URINE MUCOUS-RARE* ___ 05: 38PM GLUCOSE-87 UREA N-6 CREAT-0.5 SODIUM-136 POTASSIUM-3.9 CHLORIDE-104 TOTAL CO2-23 ANION GAP-9* ___ 05: 38PM estGFR-Using this ___ 05: 38PM ALT(SGPT)-16 AST(SGOT)-27 LD(LDH)-173 TOT BILI-<0.2 ___ 05: 38PM LIPASE-293* ___ 05: 38PM CALCIUM-8.8 PHOSPHATE-3.1 MAGNESIUM-1.9 ___ 05: 38PM WBC-14.8* RBC-4.19 HGB-12.4 HCT-37.8 MCV-90 MCH-29.6 MCHC-32.8 RDW-13.7 RDWSD-44.7 ___ 05: 38PM PLT COUNT-237 <DISCHARGE INSTRUCTIONS> You were admitted to the antepartum service for right upper abdominal pain, felt to be due to biliary colic (gallstones). You underwent a laparoscopic cholecystectomy and you recovered from your surgery well. You had no evidence of preterm labor and fetal testing was reassuring while you were here.
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Ms. ___ was admitted to the antepartum service on ___ at 22w2d gestation with RUQ pain. She underwent a RUQ ultrasound which showed cholelithiasis without evidence of cholecystitis. She was consulted by the general surgery team who recommended cholecystectomy. She was seen by the ___ team to discuss periviability and the risks of surgery as the relate to pregnancy. On ___ she underwent a laparoscopic cholecystectomy complicated by a laceration to the uterine fundus. The laceration was hemostatic and the remainder of the operation was uncomplicated, please see OMR for complete details. She recovered well in the postoperative period. By postoperative day 1 she was tolerating a regular diet, ambulating without dizziness, and pain was controlled on oral medications. There was no sign of preterm labor, preterm contractions or premature prelabor rupture of membranes. She was discharged home in ambulatory condition to resume prenatal care. Discharge Medications: 1. Acetaminophen 1000 mg PO Q6H RX *acetaminophen 500 mg ___ tablet(s) by mouth every six (6) hours Disp #*40 Tablet Refills:*1 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. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain - Moderate RX *oxycodone 5 mg 1 tablet(s) by mouth every four (4) hours Disp #*6 Tablet Refills:*0 4. Prenatal Vitamins 1 TAB PO DAILY Discharge Disposition: Home Discharge Diagnosis: pregnancy at 22w5d symptomatic gallstones Discharge Condition: stable Followup Instructions: ___
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11065553-DS-8
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> latex <ATTENDING> ___. <CHIEF COMPLAINT> Abdoinal pain <MAJOR SURGICAL OR INVASIVE PROCEDURE> none <HISTORY OF PRESENT ILLNESS> Ms. ___ is a ___ yo G2P2 who presented with gradual onset of abdominal pain starting on ___. It feels "bubbly" and is concentrated in lower quadrants bilaterally. Tolerating po's without emesis but decreased appetite. Passing flatus, last BM this morning. Developed fevers this morning (unclear tmax but 100.6 on arrival to floor). ROS otherwise negative <PAST MEDICAL HISTORY> POBHx: SVD x2, uncomplicated PGynHx: Menopausal at age ___. No post-menopausal bleeding. Denies history abnormal Paps or STIs. Sexually active in monogamous relationship with husband for last ___ years. Known fibroid uterus, never sought any treatment. PMH: Breast thrombophlebitis PSH: Denies <SOCIAL HISTORY> ___ <FAMILY HISTORY> No history of breast or GYN cancer <PHYSICAL EXAM> On admission: VS: 100.6 148/84 110 16 94%RA no I&Os recorded Gen: NAD Card: Regular, mildly tachycardiac Resp: CTAB Abd: Soft, mildly distended, diffusely tender to palpation more in lower quadrants with +voluntary guarding, no rebound. +BS Bimanual: +CMT, enlarged fibroid uterus, difficult exam secondary to patient discomfort Ext: NT, NE <PERTINENT RESULTS> ___ 08: 25AM WBC-19.0*# RBC-4.34 HGB-12.0 HCT-37.2 MCV-86 MCH-27.6 MCHC-32.2 RDW-12.4 ___ 08: 25AM PLT COUNT-285 ___ 08: 25AM LIPASE-28 ___ 08: 25AM ALT(SGPT)-15 AST(SGOT)-20 LD(LDH)-255* ALK PHOS-69 TOT BILI-0.8 ___ 08: 32AM LACTATE-2.0 ___ 12: 00AM CRP-GREATER TH <MEDICATIONS ON ADMISSION> None <DISCHARGE MEDICATIONS> 1. doxycycline hyclate 100 mg Tablet Sig: One (1) Tablet PO twice a day. Disp: *28 Tablet(s)* Refills: *0* 2. metronidazole 500 mg Tablet Sig: One (1) Tablet PO twice a day for 14 days: abstain from all alcohol while on this medication. Disp: *28 Tablet(s)* Refills: *0* 3. Lovenox 80 mg/0.8 mL Syringe Sig: One (1) Subcutaneous twice a day for 6 weeks. Disp: *84 syringe* Refills: *0* <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> possible PID (pelvic inflammatory disease) ovarian vein thrombosis <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 with abdominal pain and fevers concerning for pelvic inflammatory disease or other intra-abdominal process of unknown etiology. Imaging was unrevealing. Your blood work was also suggestive of an infection. You were treated with IV antibiotics (gentamicin and clindamycin and improved).
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Ms. ___ was initially admitted to the general surgery service. Evaluation included CT which showed no signs of appendicits, diverticulitis, or intra-abdominal abscess in the ED. GYN was asked to consult and was transferred to the GYN service for concern for PID. She was started on gent and clinda for preesumed PID despite absence of risk factors. She was febrile on the night of admission but then defervesced and remained afebrile for the duration of her admission. Her abdominal exam initially worsened with diffuse rebound; however, general surgery who continued to follow did not think surgical intervention was indicated. A repeat CT on HD 3 showed again no acute process, only a right ovarian vein thrombosis. A speculum exam was performed and some prurulent-appearing material was noted to be coming from the os. She was continued on gent/clinda. Her pain improved over the next day to almost minimal pain, and she tolerated a regular diet. On the day prior to discharge, gyn-oncology was consulted re: anticoagulation and thought this was reasonable. She was started on therapeutic lovenox. On the day of discharge she was transitioned to doxy & flagyl x14 days to treat presumed PID versus spontaneous gonadal vein thrombosis causing septic pelvic thrombophlebitis.
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11066902-DS-19
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> aspirin / G6PD <ATTENDING> ___. <CHIEF COMPLAINT> Scheduled repeat LTCS <MAJOR SURGICAL OR INVASIVE PROCEDURE> Cesarean supracervical hysterectomy <HISTORY OF PRESENT ILLNESS> ___ year old G5P2 presents for prenatal visit. This is her last visit prior to her C-section next ___. She is feeling well. She denies any vaginal bleeding or leaking fluid. Occasional contractions, but these are non-painful. +AFM. She will be going to pick up a Holter monitor this afternoon. She was recently seen in triage for a syncopal episode. She reports that she had several episodes of this as a child, and she actually was on anti-epileptic medication as a kid. In her adulthood, she started to recognize the symptoms preceding the syncopal episodes so she could deal with it better. She denies feeling any palpitations. No chest pain or shortness of breath. She has an appointment with ___ this afternoon. She continues to use Humalog 2 units with meals (breakfast, lunch, and dinner). Her fingersticks have been in the 100-140 range post-prandial. Prenatal Care: - Dating: ___ ___ by early ultrasound - Labs: O+/Ab neg/ HbSag-/ HIV-/RPRNR/ RI/ GC-/ CT-/GBS positive - Genetics: ERA LR; FFS wnl per patient report - Immunizations: declined flu, varicella immune, s/p tdap <PAST MEDICAL HISTORY> PMH: - History of ?seizures vs syncope as a child s/p normal cardiac workup - Gestational diabetes on Humolog 2 units B/L/D - Endometriosis - Migraine headaches - G6PD PSH: - Excision of abdominal wall endometrioma - LTCS OBHx: G5P2 - SVD x 1 - LTCS x 1 - SAB x 2 GYNHx: - History of endometriosis <SOCIAL HISTORY> ___ <FAMILY HISTORY> Father - T2DM <PHYSICAL EXAM> Exam on discharge: VSS Gen: NAD CV: RRR Resp: CTAB Abd: soft, non-tender, incision clean/dry/intact Ext: non-tender <PERTINENT RESULTS> CBC === ___ 12: 56PM BLOOD WBC-7.5 RBC-3.60* Hgb-9.8* Hct-30.8* MCV-86 MCH-27.2 MCHC-31.8* RDW-14.9 RDWSD-46.4* Plt ___ ___ 04: 00PM BLOOD WBC-10.4* RBC-2.32*# Hgb-6.6*# Hct-20.4*# MCV-88 MCH-28.4 MCHC-32.4 RDW-15.0 RDWSD-47.5* Plt ___ ___ 04: 40PM BLOOD WBC-15.3* RBC-2.59* Hgb-7.6* Hct-23.1* MCV-89 MCH-29.3 MCHC-32.9 RDW-14.0 RDWSD-45.1 Plt ___ ___ 06: 00PM BLOOD WBC-8.9 RBC-3.65*# Hgb-10.9*# Hct-32.3*# MCV-89 MCH-29.9 MCHC-33.7 RDW-13.3 RDWSD-43.3 Plt ___ ___ 08: 34PM BLOOD WBC-9.8 RBC-3.45* Hgb-10.0* Hct-29.0* MCV-84 MCH-29.0 MCHC-34.5 RDW-13.5 RDWSD-41.3 Plt ___ ___ 02: 22AM BLOOD WBC-8.7 RBC-2.76* Hgb-8.2* Hct-22.7* MCV-82 MCH-29.7 MCHC-36.1 RDW-13.9 RDWSD-41.1 Plt ___ ___ 07: 38AM BLOOD WBC-10.4* RBC-3.09* Hgb-9.0* Hct-25.6* MCV-83 MCH-29.1 MCHC-35.2 RDW-14.6 RDWSD-43.8 Plt ___ CHEMISTRY ========= ___ 08: 34PM BLOOD Glucose-122* UreaN-8 Creat-0.7 Na-139 K-4.1 Cl-108 HCO3-19* AnGap-16 ___ 02: 22AM BLOOD Glucose-107* UreaN-8 Creat-0.8 Na-138 K-3.4 Cl-108 HCO3-19* AnGap-14 ___ 07: 38AM BLOOD Glucose-105* UreaN-7 Creat-0.7 Na-138 K-4.1 Cl-108 HCO3-19* AnGap-15 ___ 08: 34PM BLOOD ALT-13 AST-23 LD(LDH)-273* AlkPhos-67 TotBili-1.7* DirBili-0.5* IndBili-1.2 ___ 02: 22AM BLOOD ALT-10 AST-21 LD(LDH)-231 AlkPhos-58 TotBili-1.6* DirBili-0.5* IndBili-1.1 ___ 08: 34PM BLOOD Albumin-2.7* Calcium-9.4 Phos-4.6* Mg-1.3* ___ 02: 22AM BLOOD Albumin-2.3* Calcium-8.7 Phos-3.6 Mg-2.2 ___ 07: 38AM BLOOD Calcium-7.7* Phos-4.2 Mg-1.7 IMAGING ======= ___ CXR IMPRESSION: In comparison with the study of ___, the cardiac silhouette remains within normal limits and there is no vascular congestion or acute focal pneumonia. The tip of the endotracheal tube is approximately 4.5 cm above the carina. The enteric tube extends to the stomach, with the side port at about the level of the esophagogastric junction. The tube should be pushed forward at least 5 cm for more optimal positioning. ___ CXR IMPRESSION: Comparison to ___ no relevant change. The endotracheal tube and nasogastric tube show stable position. No focal parenchymal opacities. No pneumonia. No pleural effusions. No pulmonary edema. Normal size of the cardiac silhouette. LACTATE ======= ___ 04: 00PM BLOOD Glucose-87 Lactate-3.6* Na-137 K-3.7 Cl-111* ___ 04: 30PM BLOOD Glucose-157* Lactate-3.4* Na-137 K-4.3 Cl-110* ___ 05: 20PM BLOOD Glucose-163* Lactate-3.6* Na-136 K-5.0 Cl-114* ___ 06: 09PM BLOOD Glucose-154* Lactate-2.6* Na-137 K-4.8 Cl-111* ___ 08: 36PM BLOOD Lactate-2.4* ___ 02: 45AM BLOOD Glucose-103 Lactate-1.9 COAGS/OTHER =========== ___ 08: 34PM BLOOD Hapto-14* ___ 02: 22AM BLOOD Hapto-<10* ___ 04: 00PM BLOOD ___ PTT-23.4* ___ ___ 06: 45PM BLOOD ___ ___ 08: 34PM BLOOD ___ PTT-23.1* ___ ___ 02: 22AM BLOOD ___ PTT-23.4* ___ ___ 07: 38AM BLOOD ___ PTT-24.8* ___ ___ 04: 00PM BLOOD ___ 06: 45PM BLOOD ___ 08: 34PM BLOOD ___ 02: 22AM BLOOD ___ 07: 38AM BLOOD ___ <MEDICATIONS ON ADMISSION> The Preadmission Medication list may be inaccurate and requires futher investigation. 1. Humalog 2 Units Breakfast Humalog 2 Units Lunch Humalog 2 Units Dinner 2. Prenatal Vitamins 1 TAB PO DAILY 3. Fluticasone Propionate 110mcg 2 PUFF IH BID 4. rizatriptan unknown oral ONCE: PRN migraine <DISCHARGE MEDICATIONS> 1. Acetaminophen ___ mg PO Q6H: PRN Pain do not take more than 4000 mg in 24 hours RX *acetaminophen 500 mg/5 mL ___ mL by mouth every 6 hours Refills: *2 2. Docusate Sodium 100 mg PO BID: PRN Constipation RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice a day Disp #*60 Capsule Refills: *2 3. Ibuprofen 600 mg PO Q6H: PRN Pain take with food RX *ibuprofen 600 mg 1 tablet(s) by mouth every 6 hours Disp #*50 Tablet Refills: *2 4. OxyCODONE (Immediate Release) ___ mg PO Q4H: PRN pain do not drive after taking, take with stool softener RX *oxycodone 5 mg ___ tablet(s) by mouth every 6 hours Disp #*25 Tablet Refills: *0 5. Fluticasone Propionate 110mcg 2 PUFF IH BID 6. Prenatal Vitamins 1 TAB PO DAILY 7. rizatriptan 5 mg ORAL ONCE: PRN migraine <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> Cesarean supracervical hysterectomy Postpartum hemorrhage <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 new addition to your family! The team thinks you are now stable and safe to go home. Please refer to your discharge packet and the instructions below: Nothing in the vagina for 6 weeks (No sex, douching, tampons) No heavy lifting for 6 weeks Do not drive while taking oxycodone Do not take more than 4000mg acetaminophen (APAP) in 24 hrs Do not take more than 2400mg ibuprofen in 24 hrs Please call the on-call doctor at ___ if you develop shortness of breath, dizziness, palpitations, fever of 101 or above, abdominal pain, increased redness or drainage from your incision, nausea/vomiting, heavy vaginal bleeding, or any other concerns.
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On ___, Ms. ___ was admitted to labor and delivery for an elective repeat LTCS. Her surgery was complicated by global uterine atony. After failing multiple uterotonics as well as a B Lynch suture of bilateral ovaries and ___ stitches around the uterine arteries and veins bilaterally, the decision was made to proceed with a supracervical hysterectomy given significant postpartum hemorrhage and uterine atony. Please see operative report for additional details. She subsequently received 4 units of FFP and 6 units of packed RBC's. Following her surgery, she was admitted to the FICU for close monitoring. She was transferred out of the FICU and to the post-partum floor on ___ and subsequently did well. Her Hct nadired at 25.3 and she remained asymptomatic and hemodynamically stable throughout the remainder of her hospital course. She was discharged home on ___ with appropriate follow-up scheduled.
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11068310-DS-8
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___ <CHIEF COMPLAINT> need for delivery, IUGR <MAJOR SURGICAL OR INVASIVE PROCEDURE> cesarean <HISTORY OF PRESENT ILLNESS> HPI: ___ G1 @ 35w4d with IVF mono/di twins presents for admission for daily fetal monitoring until delivery. Per US report, had ___ BPP x 2 with normal fluid x 2 (DVP 4.6/3.8), Twin A EFW 2180g (9%ile) and S/D 2.3, and twin B EFW 2017g (5%ile) with S/D 3.6. So sign of twin-twin transfusion. SVE was closed/50/post. She is currently feeling well. No contractions, lor of VB. +AFM x 2. <PAST MEDICAL HISTORY> PNC: *) Dating: ___: ___ by IVF dating *) Labs: A+/Ab-/HBsAg-/RPRNR/RI/HIVdeclined/GBS- *) Routine: - GTT wnl - U/S: FFS of twin A wnl, FFS of twin B with multiple anomalies in brain, heart, kidney, bladder, and feet (not compatible with life) - Genetics: Low risk ERA x 2, normal amnio x 2 *) Issues - IVF pregnancy (male factor infertility) - twin B with severe anomalies not compatible with life. fetal MRI at 16wks with b/l ventriculomegaly, partial agenesis of corpus callosum, cerebellar hemispheric hypoplasia with small cerebellar vermis, kined brainstem, septated nuchal cystic hygroma, b/l complete clef lip and palate, moderate microagnathia, low set ears, multiple segmentation anomalies of lower spine, short/truncated spine. Fetal echo at 18wks with complete AV canal defect and large ASD. Patient elected not to do selective reduction. - U/S: ___, A EFW 2026g, ___ BPP. B EFW 2096g with HC 97% and BPD in 99%, ___ BPP but with 11 min decel to ___. VTX/VTX POBHx: G1 PGynHx: Denies abnl paps. H/o chlamydia (treated). Normal HSG during infertility work-up (male factor infertility) PMH: occasional migraines PSH: denies Meds: PNV <SOCIAL HISTORY> ___ <FAMILY HISTORY> n/c <PHYSICAL EXAM> PE: 98.6, 121/77, 82 Gen: NAD Abd: soft, gravid, NT FHT A spot check: 135, mod var FHT B spot check: 125, mod var Toco: flat <DISCHARGE INSTRUCTIONS> given
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cs was uncomplicated baby B died on ___ she was seen by ___ and did well pp with her baby ___ ___ on Admission: none Discharge Medications: 1. Ibuprofen 600 mg PO Q6H:PRN Pain RX *ibuprofen 600 mg 1 tablet(s) by mouth q6 hours Disp #*60 Tablet Refills:*0 2. Oxycodone-Acetaminophen (5mg-325mg) ___ TAB PO Q4H:PRN Pain RX *oxycodone-acetaminophen [Percocet] 5 mg-325 mg ___ tablet(s) by mouth q4-6 hours Disp #*40 Tablet Refills:*0 Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: CS Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___
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| 198
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11068552-DS-11
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Sudafed / gluten <ATTENDING> ___. <CHIEF COMPLAINT> fibroids <MAJOR SURGICAL OR INVASIVE PROCEDURE> TOTAL ABDOMINAL HYSTERECTOMY; BILATERAL SALPINGECTOMY, RIGHT URETERAL STENT PLACEMENT, LEFT URETERAL STENT PLACEMENT AND REMOVAL, CYSTOSCOPY, RIGHT URETEROSCOPY. <HISTORY OF PRESENT ILLNESS> ___ yo with large fibroids. Of note she underwent UAE in ___ when her fibroids were 15 x 10 x 9 Imaging prior to UAE revealed likely cervical fibroid - unclear if submucosal Now uterus is 19 x 15 x 16 and cervix is no longer visualized on US Likely cervical fibroid ? degeneration vs LMS Per notes, not possible to vis cervix on exam Patient (who goes by ___ notes menses is irregular lasting ___ days. Somewhat heavy. Has pain with full bladder and bowel movement. Over past month and a half menses have stopped and she has developed flank pain. She has consulted with ___ here at ___ - she has undergone embolization twice to date and further embolization is unlikely to be helpful. She presents in consultation regarding surgical management of same. <PAST MEDICAL HISTORY> - Celiac disease - Obesity - Gestational diabetes - Asthma - ADHD - C-section: ___ years ago <SOCIAL HISTORY> ___ <FAMILY HISTORY> Paternal grandfather - colon cancer, ___ <PHYSICAL EXAM> Afebrile, vitals stable Gen: No acute distress CV: RRR Pulm: CTAB Abd: soft, appropriately tender, nondistended, incision w/ staples in place clean/dry/intact, no rebound/guarding ___: non-tender, non-edematous <PERTINENT RESULTS> ___ 07: 00PM ___ PO2-95 PCO2-52* PH-7.28* TOTAL CO2-25 BASE XS--2 INTUBATED-INTUBATED ___ 07: 00PM GLUCOSE-194* LACTATE-3.1* NA+-135 K+-3.9 CL--106 ___ 07: 00PM HGB-13.1 calcHCT-39 ___ 07: 00PM freeCa-1.19 <MEDICATIONS ON ADMISSION> DEXTROAMPHETAMINE-AMPHETAMINE [ADDERALL] - Dosage uncertain - (Prescribed by Other Provider) NAPROXEN - naproxen 500 mg tablet. 1 tablet by mouth twice a day continue for 1 week NAPROXEN - naproxen 375 mg tablet. 1 tablet(s) by mouth every twelve (12) hours as needed for pain ONDANSETRON HCL - ondansetron HCl 4 mg tablet. 1 tablet by mouth every eight (8) hours as needed for nausea OXYCODONE - oxycodone 5 mg tablet. 1 tablet by mouth every eight (8) hours as needed for pain POLYETHYLENE GLYCOL 3350 - polyethylene glycol 3350 17 gram oral powder packet. 1 powder by mouth once a day SERTRALINE - Dosage uncertain - (Prescribed by Other Provider) <DISCHARGE MEDICATIONS> 1. Acetaminophen 1000 mg PO Q8H Duration: 24 Hours Do not exceed 4000 mg per day. RX *acetaminophen 500 mg 1 to 2 tablet(s) by mouth every six (6) hours Disp #*50 Tablet Refills: *0 2. Docusate Sodium 100 mg PO BID: PRN Constipation - First Line 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 - Mild Do not exceed 2400 mg per day. Take with food. RX *ibuprofen 600 mg 1 tablet(s) by mouth every six (6) hours Disp #*50 Tablet Refills: *0 4. Oxybutynin 5 mg PO TID: PRN bladder spasms RX *oxybutynin chloride 5 mg 1 tablet(s) by mouth three times a day Disp #*50 Tablet Refills: *0 5. OxyCODONE (Immediate Release) 5 mg PO Q4H: PRN Pain - Severe RX *oxycodone 5 mg 1 tablet(s) by mouth every four (4) hours Disp #*20 Tablet Refills: *0 6. Tamsulosin 0.4 mg PO QHS: PRN stent discomfort RX *tamsulosin 0.4 mg 1 capsule(s) by mouth at bedtime Disp #*50 Capsule Refills: *0 7. Sertraline 150 mg PO DAILY <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> LEIOMYOMA 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 ___ ___ were admitted to the gynecologic oncology service after undergoing the procedures listed below. ___ have recovered well after your operation, and the team feels that ___ are safe to be discharged home. Please follow these instructions: Abdominal instructions: * Your staples will be removed within 2 weeks from your surgery. This appointment should already been scheduled for ___. Please call if ___ do not have an appointment scheduled. * Take your medications as prescribed. We recommend ___ take non-narcotics (i.e. Tylenol, ibuprofen) regularly for the first few days post-operatively, and use the narcotic as needed. As ___ start to feel better and need less medication, ___ should decrease/stop the narcotic first. * Take a stool softener to prevent constipation. ___ were prescribed Colace. If ___ continue to feel constipated and have not had a bowel movement within 48hrs of leaving the hospital ___ can take a gentle laxative such as milk of magnesium. * Do not drive while taking narcotics. * Do not combine narcotic and sedative medications or alcohol. * Do not take more than 4000mg acetaminophen (tylenol) in 24 hrs. * No strenuous activity until your post-op appointment. * Nothing in the vagina (no tampons, no douching, no sex) for 12 weeks. * No heavy lifting of objects >10 lbs for 6 weeks. * ___ may eat a regular diet. * It is safe to walk up stairs. Incision care: * ___ may shower and allow soapy water to run over incision; no scrubbing of incision. No bath tubs for 6 weeks. * Your staples, they will be removed at your follow-up visit. Constipation: * Drink ___ liters of water every day. * Incorporate 20 to 35 grams of fiber into your daily diet to maintain normal bowel function. Examples of high fiber foods include: Whole grain breads, Bran cereal, Prune juice, Fresh fruits and vegetables, Dried fruits such as dried apricots and prunes, Legumes, Nuts/seeds. * Take Colace stool softener ___ times daily. * Use Dulcolax suppository daily as needed. * Take Miralax laxative powder daily as needed. * Stop constipation medications if ___ are having loose stools or diarrhea. To reach medical records to get the records from this hospitalization sent to your doctor at home, call ___. Call your doctor at ___ for: * fever > 100.4 * severe abdominal pain * difficulty urinating * vaginal bleeding requiring >1 pad/hr * abnormal vaginal discharge * redness or drainage from incision * nausea/vomiting where ___ are unable to keep down fluids/food or your medication * chest pain or difficulty breathing * onset of any concerning symptoms
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Ms. ___ was admitted to the gynecologic oncology service after undergoing TAH BS, bilateral stent placement with left stent removal for large fibroid uterus. Please see the operative report for full details. During her procedure she had bilateral stent placement with left stent removal. KUB confirmed the stent placement. She received tamsulosin, oxybutynin and pyridium for stent discomfort. She was discharged home with tamsulosion and oxybutynin and instructed to take when experiencing stent discomfort. Her post-operative course is detailed as follows. Immediately postoperatively, her pain was controlled with an epidural. Her diet was advanced without difficulty and she was transitioned to PO tylenol/ibuprofen/oxycodone. She had an episode of oliguria and increased oxygen demand, which resolved on post-operative day 2. On post-operative day #2, her epidural was discontinued and her foley was removed because her urine output. She voided spontaneously afterwards. 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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11068569-DS-23
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> pravastatin / morphine / vancomycin / gentamicin <ATTENDING> ___ <CHIEF COMPLAINT> pelvic pain <MAJOR SURGICAL OR INVASIVE PROCEDURE> CT-guided drainage of left-sided tubo-ovarian abscess. <HISTORY OF PRESENT ILLNESS> Ms. ___ is a ___ G0 with a history of colon CA s/p sigmoid colectomy ___, morbid obesity (BMI 70), DMII who presents with abdominal pelvic pain and CT scan findings c/w ___. OB-GYN was consulted for recommendations. She reports that she has had bilateral pelvic pain that has been present for approximately 4 months worsening in intensity ___ -> ___. +Nausea but no emesis. She reports poor PO intake. Last ate meal on ___ otherwise taking only small bites of food. She also reports BRBPR (last ___ ___. Normal bowel movements. +Flatus. Denies VB or unusual discharge. Denies fevers. She has periods approximately ___ times per years. She is virginal. Of note, she was seen by her PCP and ___ CT scan was done on ___ notable for no evidence of disease recurrence, prominent retroperitoneal and porta hepatis LN that are unchanged and no new lymphadenopathy. The right adnexa was noted to be increased in prominence w/ a tublar lesion likely representing a hydrosalpinx. Unchanged large ventral/umbilical hernia containing loops of small bowel, without obstruction. <PAST MEDICAL HISTORY> - Morbid obesity - Nephrolithiasis s/p left ureteral stent - Colon cancer s/p open sigmoid colectomy c/b wound infection - Type II Diabetes mellitus - Chronic abdominal pain - s/p open sigmoid colectomy ___ (___) - s/p ex lap washout for EC fistula ___ perforated appendicitis ___ (___) - HFpEF (EF >=65% on TTE ___ <SOCIAL HISTORY> ___ <FAMILY HISTORY> Mother HYPOTHYROIDISM, HTN, metastatic endometrial cancer Father THROAT CANCER MGM DIABETES MELLITUS PGM BREAST CANCER Uncle DM Uncle Liver CA <PHYSICAL EXAM> Vitals: stable and within normal limits General: NAD, comfortable CV: RRR Resp: CTAB Abdomen: soft, non-distended, 5cm umbilical hernia easily reduced, well healed vertical midline incision. TTP in the b/l lower quadrants, no rebound or guarding. LLQ drain with scant serous fluid Extremities: no edema, no TTP <PERTINENT RESULTS> Labs on Presentation: ___ 12: 48AM BLOOD WBC-12.5* RBC-4.01 Hgb-11.3 Hct-34.9 MCV-87 MCH-28.2 MCHC-32.4 RDW-15.0 RDWSD-47.9* Plt ___ ___ 12: 48AM BLOOD Neuts-79.2* Lymphs-14.5* Monos-5.2 Eos-0.3* Baso-0.2 Im ___ AbsNeut-9.93* AbsLymp-1.81 AbsMono-0.65 AbsEos-0.04 AbsBaso-0.02 ___ 12: 48AM BLOOD Glucose-165* UreaN-28* Creat-1.3* Na-137 K-4.7 Cl-98 HCO3-28 AnGap-11 ___ 12: 48AM BLOOD Glucose-165* UreaN-28* Creat-1.3* Na-137 K-4.7 Cl-98 HCO3-28 AnGap- Peak values during admission: ___ 05: 15AM BLOOD WBC-13.1* RBC-3.91 Hgb-10.9* Hct-34.7 MCV-89 MCH-27.9 MCHC-31.4* RDW-15.5 RDWSD-49.9* Plt ___ ___ 01: 55PM BLOOD Glucose-455* UreaN-43* Creat-3.1* Na-133* K-4.2 Cl-95* HCO3-28 AnGap-10 11 At discharge: ___ 06: 24AM BLOOD WBC-4.8 RBC-3.11* Hgb-8.7* Hct-27.4* MCV-88 MCH-28.0 MCHC-31.8* RDW-14.8 RDWSD-47.8* Plt ___ ___ 06: 24AM BLOOD Glucose-261* UreaN-42* Creat-2.7* Na-137 K-3.7 Cl-98 HCO3-28 AnGap-11 <MEDICATIONS ON ADMISSION> Active Medication list as of ___: Medications - Prescription ERGOCALCIFEROL (VITAMIN D2) - ergocalciferol (vitamin D2) 50,000 unit capsule. (One) capsule(s) by mouth every other week INSULIN DEGLUDEC [TRESIBA FLEXTOUCH U-100] - Tresiba FlexTouch U-100 insulin 100 unit/mL (3 mL) subcutaneous pen. 75-78 units SQ twice a day; 75 units in the morning and 78 units in the evening. INSULIN LISPRO [ADMELOG SOLOSTAR U-100 INSULIN] - Admelog SoloStar U-100 Insulin lispro 100 unit/mL subcutaneous pen. ___ units SC before meals 151-200; 2u, 201-250; 4u, 251-300; 6u, 301-350; 8u, >351; 10u LORAZEPAM [ATIVAN] - Ativan 1 mg tablet. 1 tablet(s) by mouth 3x a day as needed for Anxiety Do not take with sedating agents or participate in activities that require mental acuity NALOXONE - naloxone 1 mg/mL injection syringe. 2 mL Intranasal Once as needed for Opiate overdose Spray 1mL each nostril. Repeat in 3min if no response. Disp x2: 2mg/2mL syringe+atomizer ONDANSETRON - ondansetron 8 mg disintegrating tablet. 1 tablet(s) by mouth three times a day as needed for nausea/vomiting OXYCODONE - oxycodone 20 mg tablet. 1 tablet(s) by mouth every four (4) hours as needed for pain DO NOT EXCEED 6 TABS PER DAY; 28 day supply TORSEMIDE - torsemide 20 mg tablet. 3 tablet(s) by mouth daily Medications - OTC ACETAMINOPHEN - acetaminophen 325 mg tablet. 2 tablet(s) by mouth every six (6) hours as needed for pain - (OTC; ___ admission med review) BISACODYL - bisacodyl 5 mg tablet,delayed release. 1 to 2 tablet(s) by mouth once a day as needed for constipation - (on discharge from rehab) BLOOD SUGAR DIAGNOSTIC [FREESTYLE LITE STRIPS] - FreeStyle Lite Strips. Use as directed to test blood glucose ___ times per day BLOOD-GLUCOSE METER [FREESTYLE LITE METER] - FreeStyle Lite Meter kit. Use as directed to test blood glucose four times a day DOCUSATE SODIUM - docusate sodium 100 mg capsule. 1 capsule(s) by mouth twice a day as needed for Constipation Take while using narcotic pain medication to reduce constipation FERROUS SULFATE - ferrous sulfate 325 mg (65 mg iron) tablet. 1 (One) tablet(s) by mouth once a day GLUCOSE [DEX4 GLUCOSE QUICK DISSOLVE] - Dex4 Glucose Quick Dissolve 4 gram chewable tablet. 1 tablet(s) by mouth every 30 min as needed for low blood sugar LANCETS [FREESTYLE LANCETS] - FreeStyle Lancets 28 gauge. Use as directed to test blood glucose ___ times per day MAGNESIUM HYDROXIDE [MILK OF MAGNESIA] - Milk of Magnesia 400 mg/5 mL oral suspension. 30 ml by mouth once a day as needed for constipation - (per discharge from rehab) MULTIVITAMIN WITH MINERALS - multivitamin with minerals tablet. 1 tablet(s) by mouth daily PEN NEEDLE, DIABETIC [BD ULTRA-FINE NANO PEN NEEDLE] - BD Ultra-Fine Nano Pen Needle 32 gauge x ___. use three times a day for finger stick testing SENNOSIDES [SENNA] - senna 8.6 mg tablet. 1 (One) tablet(s) by mouth every twelve (12) hours as needed for constipation - (per discharge from rehab) THIAMINE HCL (VITAMIN B1) - thiamine HCl (vitamin B1) 100 mg tablet. 1 tablet(s) by mouth daily <DISCHARGE MEDICATIONS> 1. Acetaminophen ___ mg PO Q6H: PRN Pain - Mild/Fever Do not take more than 4000 mg in 24 hours RX *acetaminophen 500 mg ___ tablet(s) by mouth every six (6) hours Disp #*50 Tablet Refills: *1 2. Doxycycline Hyclate 100 mg PO Q12H RX *doxycycline hyclate 100 mg 1 capsule(s) by mouth twice a day Disp #*20 Tablet Refills: *0 3. U-500 Conc 105 Units Breakfast U-500 Conc 75 Units Dinner Insulin SC Sliding Scale using HUM Insulin RX *insulin regular hum U-500 conc [Humulin R U-500 (Conc) Kwikpen] 500 unit/mL (3 mL) (concentrated) AS DIR 105 Units before BKFT; 75 Units before DINR; Disp #*6 Box Refills: *1 4. MetroNIDAZOLE 500 mg PO Q8H RX *metronidazole 500 mg 1 tablet(s) by mouth every eight (8) hours Disp #*30 Tablet Refills: *0 5. OxyCODONE (Immediate Release) 20 mg PO Q4H: PRN Pain - Moderate ___ cause sedation. Do not drink alcohol or drive while taking this medication. 6. Torsemide 20 mg PO TID <DISCHARGE DISPOSITION> Home With Service Facility: ___ <DISCHARGE DIAGNOSIS> Left-sided tubo-ovarian abscess <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Dear Ms. ___, You were admitted to the gynecology service after your procedure, an image-guided drainage of your fallopian tube abscess. You are being discharged with a drain in place. Please follow the drain care instructions carefully. 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. * Please complete the full course of antibiotics 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. * No heavy lifting of objects >10 lbs for 2 weeks. * You may eat a regular diet. * You may walk up and down stairs. ___ Drain Care: * Please look at the site every day for signs of infection (increased redness or pain, swelling, odor, yellow or bloody discharge, warm to touch, fever). * Note color, consistency, and amount of fluid in the drain. Call the doctor, ___, or ___ nurse if the amount increases significantly or changes in character. * Be sure to empty the drain bag or bulb frequently. Record the output daily. You should have a nurse doing this for you. If you do not have a nurse available, please keep close track of the amount of fluid and its appearance. * You may shower; wash the area gently with warm, soapy water. * Keep the insertion site clean and dry otherwise. * Avoid swimming, baths, hot tubs; do not submerge yourself in water. * If you develop worsening abdominal pain, fevers or chills please call Interventional Radiology at ___ at ___ and page ___. * When the drainage total is LESS THAN 10cc/ml for 2 days in a row, please call Interventional Radiology at ___ at ___ and page ___. This is the Radiology fellow on call who can assist you. Call your doctor for: * fever > 100.4F * severe abdominal pain * difficulty urinating * vaginal bleeding requiring >1 pad/hr * abnormal vaginal discharge * redness or drainage from incision/drain site * 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 presenting to the ED with abdominal pain, fevers, and imaging consistent with a tubo-ovarian abscess. She was started on intravenous antibiotics, including gentamicin, with the plan to proceed with ___ drainage of her abscess. Brief hospital course, by problem, is outlined below: Tubo-ovarian abscess: CT and TVUS obtained on HD#1 were overall consistent with tubo-ovarian abscess. She was continued on intravenous unasyn/doxycycline from ___ and then transitioned to oral flagyl/doxy on ___, which she remained on through discharge. Given her history of colon cancer, tumor markers were obtained on ___ prior to proceeding with ___ drainage. These returned wnl and overall reassuring against a malignancy, but did delay the ___ drainage until ___. On ___, a pigtail drain was placed and drained 15cc purulent fluid with prelim culture and cytology consistent with abscess secondary to E. coli infection. Overnight on ___ nursing staff noted that drain was not aspirating following routine flushing and repeat imaging was obtained, which confirmed proper location of the drain with small intermittent decrease in abscess size since initial placement. The patient was educated on proper drain maintenance, and ___ assistance was arranged to aid in care as an outpatient. ___: On initial presentation, the patient's creatinine was 1.3, elevated slightly from her most recent value of 1.1. Creatinine was trended and reached a max of 3.1 on ___, hospital day 3, before trending downward prior to discharge. Nephrology was consulted given the patient's extensive history of prior ___ (with creatinine exceeding 5.0 on prior admissions). Nephrology proceeded with urine analysis and determined the ___ to be multifactorial with exposure to contrast, signs of pre-renal etiology secondary to fluid status, and acute interstitial nephritis secondary to beta-lactam exposure. She was discharged home with stable-to-downtrending creatinine and will follow up with nephrology as an outpatient. T1DM: The patient has a history of DM, with some disparity on initial chart review of T1DM vs T2DM. This disparity was ultimately resolved on consultation and review by the ___ ___ RN who was consulted for blood sugar management. On initial presentation, pt was found to have blood sugars in the 200s-300s. Her home long acting insulin, degludec, was not on this ___'s formulary and was substituted 1:1 with glargine and she was written for sliding scale insulin. Despite this, her sugars remained persistently high with multiple instances of sugars exceeding 400 and even 500 (on hospital day hospital day 4, ___. ___ was consulted and modified her long acting insulin, starting her on U500 (105 am/75 pm), and implemented a more aggressive sliding scale insulin for correction. By the day of her discharge, her blood glucose levels were at goal within the 100-170s range. The patient was discharged home in stable condition with nursing assistance as cited above. She was scheduled for follow up with her PCP, ___, and with Dr. ___ chief resident. At the time of discharge, she had follow up appointments pending with ___ and nephrology.
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11069080-DS-15
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Penicillins <ATTENDING> ___. <CHIEF COMPLAINT> Fever <MAJOR SURGICAL OR INVASIVE PROCEDURE> Dilatation and extraction <HISTORY OF PRESENT ILLNESS> ___ yo ___ s/p D+E for MAB at ___ presents with fever to 102.4 at home around 2200. She had some bleeding yesterday, used about two pads. Has had ___ episodes of bleeding today when getting up and going to BR. No clots. No abnormal vaginal d/c. Cramping ok, but slightly worse around 6 pm. Has had a HA. No N/V/D, no cough/SOB/CP. Took tylenol at home and called MD, who recommended she come to triage for evaluation. <PAST MEDICAL HISTORY> PMH: Benign PSH: D+E for MAB <SOCIAL HISTORY> ___ <FAMILY HISTORY> NC <PHYSICAL EXAM> VS: 99.4 88 116/65 NAD RRR CTAB Abdomen: some midline lower abdominal tenderness to palpation. No r/g. No masses. +BS. No flank pain. ___: NT/NE SSE: Some old blood in vault, cleared away with a scopette. Cervical os slightly opened, appropriate from recent procedure. No increase in blood with valsalva. BME: Bulky AV uterus, tender to palpation. No distinct CMT. No adnexal masses or tenderness. <PERTINENT RESULTS> ___ 11: 19PM BLOOD WBC-18.7* RBC-3.79* Hgb-11.5* Hct-32.6* MCV-86 MCH-30.4 MCHC-35.4* RDW-12.5 Plt ___ . ___ 11: 15PM BLOOD WBC-11.1* RBC-3.51* Hgb-10.4* Hct-30.6* MCV-87 MCH-29.6 MCHC-33.9 RDW-12.4 Plt ___ . ___ 11: 19PM URINE Blood-LG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-SM . URINE CULTURE (Final ___: MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION. . ___ Ultrasound: Large amount of heterogeneous debris within the endometrial cavity which is nonvascular and could represent hematoma or devascularized retained products of conception. . ___ Ultrasound: Findings consistent with retained products of conception in the endometrial cavity. Since the examination of one day prior, contents of the endometrial cavity have also decreased consistent with evacuation of some clot. . <MEDICATIONS ON ADMISSION> Meds: Tylenol All: PCN allergic (unknown childhood reaction) <DISCHARGE MEDICATIONS> 1. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. Disp: *30 Tablet(s)* Refills: *0* 2. Doxycycline Hyclate 100 mg Tablet Sig: One (1) Tablet PO twice a day for 14 days. Disp: *28 Tablet(s)* Refills: *0* 3. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO twice a day for 14 days: Do not take with alcohol. Disp: *28 Tablet(s)* Refills: *0* 4. Diflucan 150 mg Tablet Sig: One (1) Tablet PO once as needed for yeast infection. Disp: *1 Tablet(s)* Refills: *0* <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> retained products of conception <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Lethargic but arousable. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Call your doctor for: * fever > 100.4 * severe abdominal pain * difficulty urinating * vaginal bleeding requiring >1 pad/hr * abnormal vaginal discharge * redness or drainage from incision * nausea/vomiting where you are unable to keep down fluids/food or your medication General instructions: * Take your medications as prescribed. * Do not drive while taking narcotics. * No strenuous activity, nothing in the vagina (no tampons, no douching, no sex), no heavy lifting of objects >10lbs for 6 weeks. * You may eat a regular diet.
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Patient was admitted w/fevers after ___ D&E for a missed AB and U/S concerning for retained POC's. She passed a significant amount of tissue and bleeding on HD#1 while waiting for D&C, so she was observed on IV vanc/gent/clinda and given misoprostol to hopefully promote passage of the remainder of POCs. On HD#2, she again was febrile to 101.6 and she had a repeat ultrasound which revealed less, but still present, POCs. She underwent uncomplicated U/S-guided D&E on ___. Please see full operative note for details. Patient had no post-operative complications, was afebrile > 24h, and d/c'ed with flagyl/doxy on HD#3/POD#1.
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11071428-DS-18
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> fibroids <MAJOR SURGICAL OR INVASIVE PROCEDURE> abdominal myomectomy <HISTORY OF PRESENT ILLNESS> Ms. ___ presented for MIGS consult due to fibroids, pelvic pain, menorrhagia. She notes monthly menses, lasting 6 days, heavy x 3 days requiring her to change a super pad 4x/day. During her menses, she has severe dysmenorrhea. She occasionally has overflow accidents. She notes almost nightly nocturia. She urinates ___. She denies any pain with intercourse. She denies issues with BMs. She is hoping to conceive in the next ___ years. Chart review- ___ Pap/HPV wnl ___ H/H 13.6/40.1 ___ Pelvic ultrasound: Right 10.7 x 9.3 x 9.1cm fundal subserosal fibroid. Left 11.5 x 11.3 x 9.7cm fundal subserosal fibroid. Mid- to lower uterine segment 4.5 x 4.2 x 3.5cm anterior intramural fibroid displacing the lining. 12-13mm endometrial stripe where visible. Ovaries wnl bilaterally <PAST MEDICAL HISTORY> <PAST MEDICAL HISTORY> Asthma Candidiasis Fibroids No surgical history Ob/Gyn History: G0 Regular menses. No birth control. Male partner. ___ cramping with menses <SOCIAL HISTORY> ___ <FAMILY HISTORY> non contributory <PHYSICAL EXAM> Discharge physical exam Vitals: VSS Gen: NAD, A&O x 3 CV: RRR Resp: no acute respiratory distress Abd: soft, appropriately tender, no rebound/guarding, incision c/d/i Ext: no TTP <PERTINENT RESULTS> ___ 05: 27PM BLOOD WBC-6.2 RBC-2.80* Hgb-8.3* Hct-24.7* MCV-88 MCH-29.6 MCHC-33.6 RDW-13.6 RDWSD-43.9 Plt ___ ___ 10: 40AM BLOOD WBC-5.6# RBC-2.99*# Hgb-8.7*# Hct-26.3*# MCV-88 MCH-29.1 MCHC-33.1 RDW-13.5 RDWSD-43.8 Plt ___ ___ 02: 10PM BLOOD WBC-3.5* RBC-4.23 Hgb-12.3 Hct-36.7 MCV-87 MCH-29.1 MCHC-33.5 RDW-13.2 RDWSD-41.8 Plt ___ <MEDICATIONS ON ADMISSION> ibuprofen 800 mg tablet Take 1 tablet by mouth every 8 hours as needed for pain with food oxyCODONE 5 mg tablet Take ___ tablets by mouth every 6 hours as needed for pain ALBUTEROL SULFATE HFA 90 MCG/ACTUATION AEROSOL INHALER Inhale 2 puffs as instructed with spacer every ___ hours as needed for cough or wheeze; rinse mouthpiece at least weekly <DISCHARGE MEDICATIONS> 1. Acetaminophen 1000 mg PO Q6H: PRN Pain - Mild RX *acetaminophen 500 mg ___ tablet(s) by mouth every 6 hours Disp #*50 Tablet Refills: *1 2. Docusate Sodium 100 mg PO BID 3. Ferrous Sulfate 325 mg PO DAILY RX *ferrous sulfate 325 mg (65 mg iron) 1 tablet(s) by mouth daily Disp #*28 Tablet Refills: *2 4. Ibuprofen 600 mg PO Q6H: PRN Pain - Mild Reason for PRN duplicate override: Alternating agents for similar severity RX *ibuprofen 600 mg 1 tablet(s) by mouth every 6 hours Disp #*50 Tablet Refills: *1 5. OxyCODONE (Immediate Release) ___ mg PO Q4H: PRN Pain - Moderate do not drive or drink alcohol while taking this medication. RX *oxycodone 5 mg ___ tablet(s) by mouth every 4 hours Disp #*40 Tablet Refills: *0 6. Albuterol Inhaler ___ PUFF IH Q4H: PRN wheezing, shortness of breath <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> fibroids <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Dear Ms. ___, You were admitted to the gynecology service after your procedure. You have recovered well and the team believes you are ready to be discharged home. Please call Dr. ___ office with any questions or concerns. Please follow the instructions below. General instructions: * Take your medications as prescribed. * Do not drive while taking narcotics. * Take a stool softener such as colace while taking narcotics to prevent constipation. * Do not combine narcotic and sedative medications or alcohol. * Do not take more than 4000mg acetaminophen (APAP) in 24 hrs. * No strenuous activity until your post-op appointment. * Nothing in the vagina (no tampons, no douching, no sex) for 6 weeks. * No heavy lifting of objects >10 lbs for 6 weeks. * You may eat a regular diet. * You may walk up and down stairs. Incision care: * You may shower and allow soapy water to run over incision; no scrubbing of incision. No tub baths for 6 weeks. * If you have steri-strips, leave them on. They will fall off on their own or be removed during your followup visit. * If you have staples, they will be removed at your follow-up visit. Call your doctor for: * fever > 100.4F * severe abdominal pain * difficulty urinating * vaginal bleeding requiring >1 pad/hr * abnormal vaginal discharge * redness or drainage from incision * nausea/vomiting where you are unable to keep down fluids/food or your medication To reach medical records to get the records from this hospitalization sent to your doctor at home, call ___.
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On ___, Ms. ___ was admitted to the gynecology service after undergoing abdominal myomectomy for symptomatic fibroid uterus. Please see the operative report for full details. Her post-operative course is as follows: # post operative milestones Immediately post-op, her pain was controlled with a dilaudid PCA and toradol. She was transitioned to PO oxycodone, ibuprofen, and Tylenol on post operative day 1, once she was tolerating a regular diet. Her foley was d/c'd on post operative day 1, and she voided spontaneously. # acute blood loss anemia Patient was complaining of nausea/dizziness on post operative day #2. Her heart rates had been in the high 90's-low 100's with a stable abdominal exam and reassuring blood pressures. Given concern for anemia, her hematocrit was checked and came back at 26.3 (from pre-op 36.7). Her nausea improved with Zofran. Her dizziness improved with PO intake. Orthostatics were negative. Her hematocrit was rechecked prior to discharge later in the day on post operative day #2 and was stable at 24.7. She was discharged on iron supplementation. # history of asthma Patient was continued on her home albuterol. 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 precautions and strict instructions for outpatient follow up.
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11071428-DS-19
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> hypertension <MAJOR SURGICAL OR INVASIVE PROCEDURE> classical cesarean section blood transfusion postpartum <HISTORY OF PRESENT ILLNESS> ___ yo G2P0 at 28w6d with probable history cHTN sent in for further evaluation with severe range elevated BPs in office. She notes extensive ___ swelling over the past two weeks, but denies HA, visual changes, RUQ/epigastric. She has 3+ edema today and a 9 pounds weight gain in the past two weeks. On evaluation here, she denies regular ctx, VB, LOF. Endorses active fetal movement. <PAST MEDICAL HISTORY> PNC: - ___ ___ - Labs ___ *unk* - Screening LR ERA - FFS normal - GLT *not done* - Issues: *) history of fibroids: for primary C/S ~2 and 5cm fibroids noted on NT ultrasound ___ ultrasound: LL wall 2.1 x 2.3 x 1.6 cm, anterior 2.5 x 2.7 x 1.9 cm *) CHTN - SBPs 130s outside pregnancy - PIH labs normal and 24 hour urine 192mg OBHx: - G1: SAB 5w GynHx: - fibroids (see above) - pap/HPV wnl in ___ PMH: asthma, cHTN, BMI 31 PSH: abdominal myomectomy <SOCIAL HISTORY> ___ <FAMILY HISTORY> non contributory <PHYSICAL EXAM> Admission Physical Exam Vitals: ___ 15: 00Temp.: 99.2°F ___ 15: 01BP: 148/91 (103) ___ 15: 03BP: 146/89 (102) ___ 15: 10BP: 150/83 (99) ___ 15: 20BP: 159/89 (105) ___ 15: 30BP: 143/88 (100) ___ 15: 40BP: 140/65 (84) ___ 15: 50BP: 141/81 (95) ___ 16: 00BP: 143/91 (102) ___ 16: 03BP: 164/106 (120) ___ ___: 81 Gen: A&O, comfortable Pulm: breathing comfortably on RA Abd: soft, gravid, nontender Toco: no contractions FHT 150/moderate variability/+accels/+ ? 2 late decels over 90 mins TAUS: breech <PERTINENT RESULTS> ___ 06: 54PM BLOOD WBC-4.8 RBC-4.65 Hgb-14.1 Hct-41.1 MCV-88 MCH-30.3 MCHC-34.3 RDW-13.4 RDWSD-43.4 Plt ___ ___ 03: 39AM BLOOD WBC-6.5 RBC-4.74 Hgb-14.4 Hct-41.8 MCV-88 MCH-30.4 MCHC-34.4 RDW-13.3 RDWSD-43.4 Plt ___ ___ 09: 12AM BLOOD WBC-11.4* RBC-4.19 Hgb-12.7 Hct-37.1 MCV-89 MCH-30.3 MCHC-34.2 RDW-13.3 RDWSD-43.5 Plt ___ ___ 06: 17AM BLOOD WBC-9.4 RBC-2.12* Hgb-6.4* Hct-19.6* MCV-93 MCH-30.2 MCHC-32.7 RDW-14.1 RDWSD-47.8* Plt ___ ___ 07: 40AM BLOOD WBC-10.4* RBC-2.87* Hgb-8.6* Hct-25.8* MCV-90 MCH-30.0 MCHC-33.3 RDW-14.4 RDWSD-46.4* Plt ___ ___ 12: 40PM BLOOD Creat-1.1 ___ 06: 54PM BLOOD Creat-1.2* ___ 03: 39AM BLOOD Creat-1.2* K-4.3 ___ 07: 40AM BLOOD Creat-0.6 ___ 03: 39AM BLOOD ALT-59* AST-68* ___ 03: 54PM BLOOD ALT-54* AST-71* ___ 03: 35PM BLOOD ALT-80* AST-107* LD(LDH)-439* ___ 05: 58AM BLOOD ALT-90* AST-127* LD(___)-389* ___ 07: 40AM BLOOD ALT-58* AST-57* ___ 11: 39AM BLOOD Mg-9.6* ___ 03: 54PM BLOOD Mg-7.9* ___ 07: 07PM BLOOD Calcium-6.9* Phos-7.2* Mg-7.0* ___ 11: 46PM BLOOD K-4.7 <MEDICATIONS ON ADMISSION> PNV, albuterol, budesonide <DISCHARGE MEDICATIONS> 1. Docusate Sodium 100 mg PO BID: PRN Constipation take as needed for constipation RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice a day Disp #*60 Capsule Refills: *4 2. Ferrous Sulfate 325 mg PO DAILY RX *ferrous sulfate [Iron (ferrous sulfate)] 325 mg (65 mg iron) 1 (One) tablet(s) by mouth twice a day Disp #*60 Tablet Refills: *0 RX *ferrous sulfate [Feosol] 325 mg (65 mg iron) 1 tablet(s) by mouth daily Disp #*60 Tablet Refills: *4 3. Ibuprofen 600 mg PO Q8H: PRN Pain - Moderate take with food RX *ibuprofen [IBU] 600 mg 1 (One) tablet(s) by mouth every six (6) hours Disp #*40 Tablet Refills: *0 RX *ibuprofen [IBU] 600 mg 1 tablet(s) by mouth every 6 hours Disp #*30 Tablet Refills: *1 4. NIFEdipine (Extended Release) 60 mg PO QAM Take 1 tablet twice a day RX *nifedipine [Adalat CC] 60 mg 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills: *2 5. OxyCODONE (Immediate Release) ___ mg PO Q4H: PRN pain RX *oxycodone 5 mg 1 (One) tablet(s) by mouth every six (6) hours Disp #*20 Tablet Refills: *0 RX *oxycodone [Oxaydo] 5 mg 1 tablet(s) by mouth every 4 to 6 hours as needed Disp #*12 Tablet Refills: *0 6. Ranitidine 150 mg PO DAILY RX *ranitidine HCl [Acid Control (ranitidine)] 150 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills: *4 <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> low transverse C-section super imposed Pre-eclampsia (severe features based on blood pressure and renal testing) and Hypertension/HELLP syndrome Anemia requiring transfusion <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> See written instructions reviewed by RN and OB provider in discharge packet.
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Ms ___ was admitted to the antepartum service on ___ with severe range bp in the office. She was started on nifedipine 30mg CR and labs were drawn which were notable for a creatinine of 0.8 (baseline 0.64) and proteinuria with spot P/C ratio of 5.5. She received betamethasone for fetal lung maturity. On ___ a 24 urine confirmed the diagnosis of pre-eclampsia with over 7000mg protein in a 24 hour urine volume of only 900cc. Formal ultrasound was done showing a well grown fetus with normal amniotic fluid. She had daily labs and remained stable on nifedipine until ___ when she again developed severe range blood pressures and her nifedipine was up-titrated to 30mg Cr in the am and 60mg CR in the pm. On ___ her labs showed a continuing worsening trend with slightly elevated LFTs, slightly downtrending platelets, creatinine of 1.0. MFM was consulted. On ___ the patient reported chest/left upper abdominal pain which resolved, her EKG was normal and her blood work was notable for a Cr 1.1 and mildly elevated LFTs. She developed severe range BPs and was given Nifedipine 10 mg po as well as transferred to the Birthing Unit. She later required 20 mg Labetolol IV dose as well for additional severe range blood pressures. On ___, she required IV Labetalol 20mg for severe range BPs. She was stareted on Nifedipine 60mg PO BID. Her blood work was stable. She was started on Magnesium as well during this time and was later stopped. There was a concern for Oliguria and her Cr increased to 1.2. After consultation with ___, the decision was made to deliver that patient. She was counseled on the need for a cesarean section given her prior myomectomy and breech presentation. She underwent a classical cesarean section because of dense adhesive disease seen on the uterus. Postpartum she continued the nifedipine for blood pressure control and was on Magnesium sulfate. Given her renal compromise, she was closely followed with Magnesium levels, which several hours after delivery became very elevated (9.6). The Magnesium was stopped for this reason, but her magnesium levels throughout the first 24 hours postpartum remained therapeutic. Also her potassium was noted to be elevated and internal medicine was consulted. After testing potassium using whole blood sample, the value was normal and no further workup was needed. Her blood pressures remained well controlled on Nifedipine 60mg BID. Her blood work showed eventual normalizing of her Cr to 0.6 and her LFTs were downtrending. Her HCT was noted post-op to be stable at 19.0 (due to blood loss, and likely initial testing reflecting extreme hemoconcentration). She agreed to a blood transfusion on POD#3 after counseling and her post-transfusion blood work showed an appropriate rise in her HCT. She also underwent a right lower extremity doppler for R>L edema which showed no evidence of a DVT. She was kept on heparin for DVT ppx postpartum. She felt very well and was discharged home on POD#4 with close f/u in the office.
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11071748-DS-18
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Cephalosporins / adhesive <ATTENDING> ___. <CHIEF COMPLAINT> Right sided back pain <MAJOR SURGICAL OR INVASIVE PROCEDURE> none <HISTORY OF PRESENT ILLNESS> ___ yo G2P at 37w6d with hx of UTIs in pregnancy, nephrolithiasis presents with right sided back pain. Has been on macrobid for four days for UTI. Denies fever, chest pain, ctx, VB, LOF. +FM. She does report severe nausea today that she is unable to eat. She denies emesis. Per on call physician at ___, most recent grew citerobacter >100,000 resistant to macrobid but sensitive to augmentin and gentamicin. We are unable to get prenatal records today per the on-call physician. <PAST MEDICAL HISTORY> PNC: no records available, all per patient history - ___ ___ - Labs A+/Abs- - Screening: low risk per patient - FFS, glucose screen all normal per patient - Issues: *) One prior UTI in pregnancy OBHx: G2P0 - G1: ectopic s/p MTX GynHx: - Denies abnormal Pap, fibroids, Gyn surgery, STIs PMH: - Nephrolithiasis - PCOS - Interstitial cystitis PSH: - Wisdom tooth extraction - T+A - Ganglion cyst removal - ___ eye surgery <SOCIAL HISTORY> ___ <FAMILY HISTORY> n/a <PHYSICAL EXAM> Exam on admission VS: T-97.8 HR-109 BP-133/79 Gen: A&O, comfortable CV: RRR PULM: CTAB Abd: soft, gravid, nontender EFW 8# by Leopolds Back: positive CVA tenderness Ext: no calf tenderness SVE: ___ Toco flat FHT 125/moderate varability/+accels/-decels <PERTINENT RESULTS> ___ 11: 50AM BLOOD WBC-15.2* RBC-4.68 Hgb-13.0 Hct-39.9 MCV-85 MCH-27.8 MCHC-32.6 RDW-14.1 Plt ___ ___ 11: 50AM BLOOD Neuts-80.7* Lymphs-10.5* Monos-7.7 Eos-0.9 Baso-0.3 ___ 11: 50AM BLOOD ___ PTT-28.8 ___ ___ 11: 50AM BLOOD Glucose-84 UreaN-11 Creat-0.8 Na-136 K-4.0 Cl-103 HCO3-23 AnGap-14 ___ 11: 50AM BLOOD Calcium-9.2 Phos-3.6 Mg-1.9 ___ 12: 05PM URINE Color-Yellow Appear-Hazy Sp ___ ___ 12: 05PM URINE Blood-NEG Nitrite-NEG Protein-30 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-SM ___ 12: 05PM URINE RBC-4* WBC-8* Bacteri-FEW Yeast-NONE Epi-27 TransE-<1 URINE CULTURE (Final ___: MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION. PATHOLOGY # ___ CALCULUS, KIDNEY, GROSS ONLY Renal ultrasound ___: IMPRESSION: Mild-to-moderate right hydronephrosis. No nephrolithiasis is identified. <MEDICATIONS ON ADMISSION> PNV, macrobid, prilosec, folic acid, urostat <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 #*28 Tablet Refills: *0 2. HYDROmorphone (Dilaudid) ___ mg PO Q4H: PRN pain RX *hydromorphone 2 mg ___ tablet(s) by mouth every four (4) hours Disp #*12 Tablet Refills: *0 <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> pyelonephritis, kidney infection <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 ___ obstetrical service at ___ ___ for pain and nausea in the setting of a urinary tract infection thought to be related to a kidney infection and a kidney stones. You had an ultrasound of your kidneys that did not show stones but you passed possibly a kidney stone prior to discharge. You were treated with intravenous antibiotics and pain medication and you improved. You were then transitioned to oral antibiotics and pain medication and you did well. You were therefore felt to be safe to return home to follow up with your obstetrician. You did not show any signs of labor while you were admitted to the hospital. *please take your medications as prescribed *please finish your full 14 days course of antibiotics *please stay well hydrated *please call your doctor or seek medical care for fever/chills, nausea/vomiting, worsening pain, signs of labor or any other symptoms that concern you
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Ms. ___ was admitted to the hospital with right sided flank pain and concern for both nephrolithiasis and pyelonephritis. She was initially unable to tolerate a regular diet. The sensitivities from her urine culture the week prior were requested and received and she was started on IV gentamicin. She continued the gentamicin for 24 hours. Her pain was initially controlled with a dilaudid PCA. By hospital day 2 she had passed two small nephrolithiasis. She remained afebrile and her pain significantly improved. She was transitioned to oral pain medications and augmentin for treatment of her infection. She had reassuring fetal status throughout her hospital stay. She was discharged home in good condition on hospital day 2. She is to have close follow-up with her primary obstetrician, Dr. ___.
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11071875-DS-19
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Aspirin / Bactrim <ATTENDING> ___. <CHIEF COMPLAINT> right sided back pain <MAJOR SURGICAL OR INVASIVE PROCEDURE> ___ guided percutaneous nephrostomy tube <HISTORY OF PRESENT ILLNESS> Patient is a ___ yo G5P2 at ___ gestational age who presents with severe right sided back pain radiating to the right side of her abdomen and groin. Pain started suddenly at 0230 and was ___ at the worst improving to ___ baseline. Pain is colicky and associated with nausea and diaphoresis. Denies emesis, hematuria, dysuria, fever, chills, contractions, vaginal bleeding, leakage of fluid. Pain is not improved by any position. She has not tried pain medication. She had a soft formed BM yesterday and has had normal appetite. Of note she was seen in triage ___ for abdominal pain and back pain that was mostly on the left at the time. She reports this pain is similar just mainly on the opposite side. She had a UA positive for nitrites but urine culture was negative. She did not have imaging. Please see note by Dr. ___ details. She endorses active FM and denies any vaginal bleeding or leaking of fluid. <PAST MEDICAL HISTORY> PNC: 1. ___: ___ 2. A+/Ab neg/HBsAg neg/RPR NR/RI/GBS unknown 3. Declined aneuploidy screening 4. Nml FFS OBHx: SVD ___ @ 37 weeks, female, weight 7#9 SAB x 2-> D&C x 2 SVD ___ @ 36 weeks, female, weight 7#10 GynHx: Patient denies any history of Gyn PMH: Graves Disease s/p ablation PSH: D&C x 2 <SOCIAL HISTORY> ___ <FAMILY HISTORY> non-contributory <PHYSICAL EXAM> (on admission) T: HR: BP: Appears in significant discomfort, with intermittent peaks and ebbs CV: RRR Pulm: CTAB Abd: Gravid, + BS, NT, no uterine tenderness specifically, no guarding and no rebound Flank: Positive to palpation, (+) CVAT on right. No tenderness of left FHR: 150/mod/+accel/no decel TOCO: Flat US: BPP ___, Transverse, head to maternal left, posterior fundal placenta grossly normal, AFI 13.1cm <PERTINENT RESULTS> ___ WBC-10.8 RBC-3.46 Hgb-9.8 Hct-29.6 MCV-86 Plt-202 ___ Neuts-86.3 ___ Monos-3.0 Eos-0.4 Baso-0.2 ___ WBC-5.7 RBC-3.38 Hgb-9.9 Hct-27.8 MCV-82 Plt-179 ___ Neuts-89 Bands-5 ___ Monos-0 Eos-0 Baso-0 Atyps-0 ___ Myelos-0 ___ WBC-15.2 RBC-2.94 Hgb-8.6 Hct-24.9 MCV-85 Plt-185 ___ Neuts-90.4 ___ Monos-2.6 Eos-0.8 Baso-0.1 ___ ___ PTT-29.1 ___ ___ Glu-98 UreaN-12 Cre-0.6 Na-133 K-3.8 Cl-101 HCO3-22 ___ BUN-8 Creat-0.6 ___ Glu-76 BUN-6 Cre-0.4 Na-138 K-3.3 Cl-106 HCO3-24 ___ ALT-10 AST-19 Amylase-75 TotBili-0.2 Lipase-34 ___ Calcium-8.6 Phos-4.1 Mg-1.7 ___ Calcium-7.8 Phos-3.8 Mg-1.7 ___ 09: 56AM URINE Blood-VERIFIED Nitrite-POS Protein-30 Glucose-NEG Ketone-10 Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-TR ___ 09: 56AM URINE RBC-VERIFIED WBC-1 Bacteri-MOD Yeast-NONE Epi-1 URINE CULTURE (Final ___: NO GROWTH URINE CULTURE (Final ___: NO GROWTH <MEDICATIONS ON ADMISSION> Synthroid ___ QD PNV <DISCHARGE MEDICATIONS> 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for Constipation. Disp: *60 Capsule(s)* Refills: *0* 2. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 3. Hydromorphone 2 mg Tablet Sig: ___ Tablets PO Q3H (every 3 hours) as needed for pain. Disp: *15 Tablet(s)* Refills: *0* 4. Levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Amoxicillin-Pot Clavulanate 500-125 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) for 12 days. Disp: *36 Tablet(s)* Refills: *0* 6. Keflex ___ mg Capsule Sig: One (1) Capsule PO at bedtime: please start after finishing course of Augmentin, continue until end of pregnancy. Disp: *30 Capsule(s)* Refills: *3* <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> Pyelonephritis Obstruction of right ureter probably by kidney stones Hydronephrosis <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> - Please follow the provided instructions for care of your nephrostomy tube. - Augmentin has been prescribed to treat your infection. Take 1 tablet 3 times a day for 14 days total. - You will need prophylatic antibiotics after your treatment to prevent recurrence especially due to your kidney stone. Take Keflex ___ mg once a day at bedtime. Start after completing Augmentin
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Ms ___ is a ___ G5P2 at 30w6d with nephrolithiasis and UTI. She was admitted for IV hydration, antibiotics, pain control, and urology consultation. She was initially afebrile and had a normal white blood cell count. She was treated with IV Ceftriaxone and her pain was controlled with a Dilaudid PCA. Urology was consulted and recommended conservative management. On hospital day #2, she became febrile to 102.7 and hypotensive. Repeat white blood cell count was 5.7 with 5% bands. She remained febrile despite 1 gram of tylenol. Blood cultures were sent and repeat white blood cell count became quite elevated (21.3). Given the concern for obstruction and urosepsis, urology placed a right percutaneous nephrostomy tube on ___. Her pain was significantly improved once the nephrostomy tube was placed. She was continued on IV Ceftriaxone and closely observed. She continued to improved clinically and remained afebrile for 48 hours. Although the urine culture was negative, urology recommended continuing a 14 day course of antibiotics and suppression for the remainder of the pregnancy. . *)FWB: Fetal testing was reassuring throughout this admission. She had no obstetric concerns. . *)Prior to discharge, Ms ___ complained of a painful, hard venous cord in popliteal fossa of left leg. Ultrasound confirmed a thrombosis of a superfical varicose vein, with no evidence of DVT.
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11071924-DS-19
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Keflex / Erythromycin Base <ATTENDING> ___. <CHIEF COMPLAINT> endometriosis and chronic pelvic pain <MAJOR SURGICAL OR INVASIVE PROCEDURE> attempted laparopscopic hysterectomy, converted to total abdominal hysterectomy, bilateral salpingo-oophorectomy, cystoscopy <HISTORY OF PRESENT ILLNESS> ___ yo G1P1 with chronic endometriosis. ___ has been on lupron for several years and would like definite treatment. Patient also reports a rash that spikes following is also getting a rash that flares after lupron injections. <PAST MEDICAL HISTORY> PAST MEDICAL HISTORY: 1. Asthma 2. Endometriosis PAST SURGICAL HISTORY 1. Umbilical hernia: Repair and subsequent excision of endometriosis from incision scar. GYN HX: Menopausal symptoms: pt with menopausal symptoms and amenorrhea on lupron Last pap: ___. Result: NORMAL. Last mammogram: ___. Last bone density: ___. Infection/STI history: None. Contraception: Nothing. OBSTETRICAL HISTORY 1. G1P1 SVD (___) <SOCIAL HISTORY> ___ <FAMILY HISTORY> Noncontributory <PHYSICAL EXAM> Exam on day of discharge AFVSS NAD, A&O x3 CTAB RRR AB: nd/nt, no rebound, no gaurding, incision c/d/i ___: nt/ne/no cords <MEDICATIONS ON ADMISSION> MEDICATIONS ibuprofen leuprolide oxycodone triamcinolone acetonide valacyclovir docusate sodium [Colace] <DISCHARGE MEDICATIONS> 1. Docusate Sodium 100 mg PO BID take when taking oxycodone to prevent constipation 2. Oxycodone-Acetaminophen (5mg-325mg) ___ TAB PO Q4H: PRN pain Do not take more than 4000mg acetaminophen per day. Do not drive or drink alcohol. 3. Ibuprofen 600 mg PO Q8H: PRN pain <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> endometriosis, pelvic pain <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Dear Ms. ___, You were admitted to the gynecology service after your procedure. You have recovered well and the team believes you are ready to be discharged home. Please call Dr. ___ office with any questions or concerns. Please follow the instructions below. General instructions: * Take your medications as prescribed. * Do not drive while taking narcotics. * Take a stool softener such as colace while taking narcotics to prevent constipation. * Do not combine narcotic and sedative medications or alcohol. * Do not take more than 4000mg acetaminophen (APAP) in 24 hrs. * No strenuous activity until your post-op appointment. * Nothing in the vagina (no tampons, no douching, no sex) for 6 weeks. * No heavy lifting of objects >10 lbs for 6 weeks. * You may eat a regular diet. * You may walk up and down stairs. Incision care: * You may shower and allow soapy water to run over incision; no scrubbing of incision. No bath tubs for 6 weeks. * If you have steri-strips, leave them on. They will fall off on their own or be removed during your followup visit. * If you have staples, they will be removed at your follow-up visit. To reach medical records to get the records from this hospitalization sent to your doctor at home, call ___.
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Ms ___ underwent a laparoscopic converted intraoperatively to a total abdominal hysterectomy, bilateral salpingo-oophorectomy, cystoscopy; see operative report for details. She had an uncomplicated recovery and was discharged home on postoperative day #2 in good condition: ambulating and voiding without difficulty, tolerating a regular diet, and with adequate pain control using PO medication.
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11072056-DS-16
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Patient recorded as having No Known Allergies to Drugs <ATTENDING> ___ <CHIEF COMPLAINT> ovarian cancer <MAJOR SURGICAL OR INVASIVE PROCEDURE> Debulking surgery including colectomy with end ileostomy, cholecystectomy, R oopherectomy, placement of bilateral J-P drains, placement of GJ tube. <HISTORY OF PRESENT ILLNESS> Ms ___ is a ___ year old woman with advanced ovarian cancer who underwent debulking surgery today. This ultimately involved a total colectomy with end ileostomy; R oopherectomy; placement of a G-J tube; and a cholecystectomy. The uterus and ovaries could not be removed because of tumor encasing the uterus, ovaries, and bladder; there was large omental caking; and thus, significant amounts of tumor had to be left in the abdomen. There were no major complications of the surgery, but given the extent of the surgery and the possibility of post-operative difficulties, the ob/gyn and general surgery services (both working on the case) agreed that she would be best cared for in an intensive care unit tonight. . Over the last six months, Ms ___ has lost approximately 20 pounds, and has had a number of exacerbations of her anxiety, increased vegetative symptoms, and a significant fear of falling; she was admitted to the ___ unit from ___ for these symptoms. She was noted to have a distended abdomen; a CT revealed omental cake, adnexal masses, and massive ascites. A CA-125 level was 548. Colonoscopy revealed strictures, and a barium enema confirmed them; peritoneal cytology revealed malignant cells consistent with ovarian cancer. After consultation with a gynecological oncology specialist she elected to proceed with the surgery undertaken today. . Post-operatively she is somewhat groggy and does not want to open her eyes, and does not want to hear about her surgery. She is complaining of pain in the lower abdomen as well as her chronic lower back pain (for which she uses a fentanyl patch as an outpatient). She is also complaining of nausea. She denies any discomfort or pain other than these three problems. Specifically, she denies any difficulty with breathing or chest pain or dyspnea. . <PAST MEDICAL HISTORY> Stage IIIC ovarian cancer, hypertension, depression, anxiety, chronic low back pain, osteoarthritis, IBS, anemia, glaucoma. Past surgical hx: D&C for spontaneous abortion, many years ago. <SOCIAL HISTORY> ___ <FAMILY HISTORY> Patient reports her mother had "liver cancer" in her ___ no other history of malignancy. <PHYSICAL EXAM> (Post-operative exam, in ___ ICU) . VS: Temp: 98.6 BP: 111/59 HR: 79 RR: 14 O2sat: 100 GEN: lying still w eyes closed, non-toxic appearing, breathing without difficulty, in evident discomfort by facial expression HEENT: MMM, OP w slight blood at posterior aspect c/w intubation injury; refuses to open eyes NECK: no carotid bruits RESP: CTA b/l with good air movement throughout on anterior exam CV: RR, S1 and S2 wnl, no m/r/g ABD: drains and ostomy in place, dressed, draining. J-P drains draining copious serosanguinous fluid. Some tenderness to palpation; extensive palpation deferred given pain. EXT: no c/c/e, cool, good pulses SKIN: no rashes/no jaundice NEURO: AAO. ___ strength at grip, dorsi/plantarflexion, biceps; symmetrical. No sensory deficits to light touch appreciated at extremities. For cold glove test, feels cold sensation to approx T8 from below. <PERTINENT RESULTS> ___ 07: 11PM WBC-17.6*# RBC-4.98 HGB-14.4# HCT-43.4 MCV-87 MCH-28.9 MCHC-33.2 RDW-14.4 ___ 07: 11PM PLT COUNT-326 ___ 07: 11PM GLUCOSE-160* UREA N-10 CREAT-0.5 SODIUM-144 POTASSIUM-4.4 CHLORIDE-110* TOTAL CO2-21* ANION GAP-17 ___ 07: 11PM CALCIUM-8.0* PHOSPHATE-4.7* MAGNESIUM-1.6 ___ 05: 07PM GLUCOSE-168* LACTATE-1.9 NA+-135 K+-4.3 CL--106 ___ 05: 07PM HGB-13.3 calcHCT-40 ___ 05: 07PM freeCa-1.03* ___ 05: 07PM TYPE-ART RATES-/10 TIDAL VOL-400 O2-33 O2 FLOW-0.5 PO2-134* PCO2-40 PH-7.38 TOTAL CO2-25 BASE XS-0 INTUBATED-INTUBATED VENT-CONTROLLED ___ 05: 59AM BLOOD WBC-5.7 RBC-2.83* Hgb-7.8* Hct-24.6* MCV-87 MCH-27.5 MCHC-31.6 RDW-15.3 Plt ___ ___ 02: 46AM BLOOD Neuts-88.3* Bands-0 Lymphs-6.2* Monos-5.2 Eos-0.2 Baso-0.1 ___ 04: 23PM BLOOD ___ PTT-28.9 ___ ___ 05: 59AM BLOOD Glucose-154* UreaN-6 Creat-0.5 Na-140 K-4.4 Cl-105 HCO3-30 AnGap-9 ___ 04: 23PM BLOOD ALT-6 AST-13 AlkPhos-73 TotBili-0.3 ___ 04: 23PM BLOOD VitB12-509 Folate-6.7 ___ 04: 23PM BLOOD TSH-6.3* ___ 05: 23AM BLOOD Free T4-0.95 <MEDICATIONS ON ADMISSION> Lorazepam 0.5 mg BID Colace 100 mg BID Fentanyl patch 50 mcg/hr q72 hrs Imipramine 50 mg nightly Lisinopril 30 mg q AM Amlodipine 5 mg q AM Pantoprazole 40 mg daily Mirtazapine 15 mg nightly Timolol (opthalmic) 0.25% one drop each eye once daily Sertraline 100 mg <DISCHARGE MEDICATIONS> 1. Cyanocobalamin 100 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp: *30 Tablet(s)* Refills: *2* 2. Sertraline 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp: *30 Tablet(s)* Refills: *2* 3. Timolol Maleate 0.25 % Drops Sig: One (1) Drop Ophthalmic DAILY (Daily). Disp: *5 mL* Refills: *2* 4. Mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). Disp: *30 Tablet(s)* Refills: *2* 5. Fentanyl 50 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr Transdermal Q72H (every 72 hours). Disp: *10 Patch 72 hr(s)* Refills: *2* 6. Lisinopril 10 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). Disp: *60 Tablet(s)* Refills: *2* 7. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO QID (4 times a day). Disp: *120 Tablet, Chewable(s)* Refills: *2* 8. Hydromorphone 2 mg Tablet Sig: ___ Tablets PO Q3H (every 3 hours) as needed for pain. Disp: *90 Tablet(s)* Refills: *0* 9. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID PRN () as needed for anxiety. Disp: *60 Tablet(s)* Refills: *0* 10. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp: *30 Tablet(s)* Refills: *2* <DISCHARGE DISPOSITION> Extended Care Facility: ___ <DISCHARGE DIAGNOSIS> advanced ovarian cancer depression anxiety glaucoma <DISCHARGE CONDITION> stable <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Please call your doctor for increased abdominal pain, fevers, chills, chest pain, shortness of breath, leg pain/swelling, any concerns. No heavy lifting x 6 wks.
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This is a ___ year old woman with advanced ovarian cancer with widespread abdominal involvement, who was admitted ___ status post colectomy w end ileostomy, cholecystectomy, R oopherectomy, and debulking, with placement of a G-J tube, two ___ drains, a GJ tube. . # Intraoperative course: On ___ the pt underwent exam under anesthesia, exploratory laparotomy, right salpingo-oophorectomy, and drainage of 4 liters ascites by Dr ___. This was followed by lysis of adhesions, abdominal colectomy, end ileostomy with ___ pouch of rectum, gastrojejunostomy feeding tube, and open cholecystectomy by Dr ___. The surgery was uncomplicated. Estimated blood loss was 800 cc. She developed hypotension intraoperatively and was transfused 2 units of packed RBCs. Intraoperative findings were significant for studding of all peritoneal surfaces, a solid cake of tumor from the top of the bladder back to the sacral promontory with indistinct tissue plains, tumor infiltration into retroperitoneal spaces, tumor compression of ileocecal portion of the bowel, complete replacement of the infracolic omentum with 15 cm tumor, tumor extension along the infragastric omentum and lesser sac, studding of diaphragmatic surfaces bilaterally. Upon completion of surgery, the colon had been removed to the level of the sacral promontory, tumor remained within the pelvis, and approximatedly 70% of tumor was removed. Please see dictated operative reports for full details. . #. Cardiovascular: Pt developed fluid responsive hypotension on POD#0, due to post-operative fluid shifts and medication effects of the epidural. Blood pressure rose to normal levels within the ICU admission; fluid boluses were used to maintain pressure and hydration during the post-operative course. As pt's blood pressure reached high normal, her outpatient medication regimen of amlodipine and lisinopril were restarted. Her blood pressure remained stable within normal limits for the remainder of the hospitalization. . #. GU: The pt had borderline urine output on POD#0 that resolved with IV fluid hydration. Her urine output remained adequate for the duration of hospitalization. Her foley was discontinued on POD#6. She voided without difficulty during the day, but experienced urinary incontinence thoughout that night. This was thought to be a combination of timely ambulation and discontinuation of her home imipramine per psych recommendations. UA and Ucx were neg for UTI. Incontinence resolved. . #. Heme: The pt received 2 units of packed RBCs intraoperatively. Hematocrit fluxes were most consistent with fluid shifts; she did not appear to have major post-operative blood loss. She remained asymptomatic from her anemia for the duration of her hospitalization and her Hct was stable ___. . #. Neuro: Post-operative pain was initially managed with an epidural, but the epidural fell out and a fentanyl PCA was started for control of pain. She was transitioned to dilaudid pca, then dilaudid po with adequate pain control. Fentanyl Patch 50 mcg/hr TP Q72H was continued throughout hospitalization. . # GI. Continued zofran and prochlorperazine initially; however, discontinued the latter with delirium (below). Ativan discontinued per psych recs, and prn zyprexa added for nausea. The stoma nurse began ostomy teaching as in inpt and will continue to follow as an outpt. . # Infectious disease. Surgery recommended 4 days ceftazidime and flagyl for ppx against intrabdominal infection. Pt had 2 isolated low grade fevers. Work ups were negative for infection. Pt was not restarted on further antibiotics. These temperatures were attributed to atelectasis and insentive spirometry and ambulation were encouraged. . # Depression/anxiety. During MICU course the patient had some delirium and confusion. The psychiatry service was consulted. Per their recs, we obtained MRI head, which was read as no metastatic disease; TSH, folate, B12; and discontinued her ativan, imipramine and prochlorperazine, while adding olanzapine for nausea and anxiety. We continued her home mirtazapine and sertraline. Confusion resolved and pt was restarted on home ativan dose without recurrance of symptoms. Pt will need outpt psychiatry follow up. . # HEENT. Continue home timolol for glaucoma. . # FEN. Tube feeds through the GJ tube were started on ___ and advanced to 60cc/hr for 10 hrs a day. Pt was tolerating solids po at the time of discharge. However, calorie counts remained inadequate and pt was discharged with tube feeds. Electrolytes were checked daily and repleted prn. . #. Ovarian Ca, s/p debulking. Pt will follow up as outpt with Dr ___ discussion of chemotherapeutic options. . # PPX. Pneumoboots. Heparin SC. PPI . # CODE. DNI/DNR . # COMMUNICATION. With patient.
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11081971-DS-19
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> flank pain, fever <MAJOR SURGICAL OR INVASIVE PROCEDURE> none <HISTORY OF PRESENT ILLNESS> ___ yo G2P1 @ ___ transferred from the ED with L flank pain, fevers, leukocytosis, c/w pyelonephritis. Patient had a week of fevers, myalgias attributed to viral illness, more likely prodrome. Denied any dysuria or hematuria during the past week. Has overall been hydrating well and denies any ctx. Denies LOF, VB. ROS negative for cough, URI sx, CP, SOB, N/V/D, abnormal bleeding or discharge. Denies sick contacts. PNC: - ___ ___ by LMP c/w ___ wk US - Labs: Rh*NEG*/Abs-/RubImm/RPR/HBsAg/HIV/GBS - Screening: low risk panorama, boy OBHx: - G1: SVD 40 wks ___ - G2: current GynHx: - ___: ___, HPV+ - denies fibroids, Gyn surgery, STIs <PAST MEDICAL HISTORY> PMH: - Asthma - Childhood murmur PSH: - Gastric sleeve ___ (___) - Tibial fx repair w/ metal plates (___) <SOCIAL HISTORY> ___ <FAMILY HISTORY> n/c <PHYSICAL EXAM> Gen: A&O, comfortable PULM: no increased WOB, CTAB CV: RRR Abd: soft, nontender Back: L CVA tenderness Ext: WWP EFW by ___: small TAUS: 303g, breech, ? low lying placenta (difficult to assess w/ full bladder) SVE: deferred FHT: 150s <PERTINENT RESULTS> ___ 07: 40PM URINE RBC-2 WBC->182* BACTERIA-MOD* YEAST-NONE EPI-0 ___ 07: 40PM URINE BLOOD-SM* NITRITE-POS* PROTEIN-TR* GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 LEUK-LG* ___ 07: 40PM PLT COUNT-195 ___ 07: 40PM WBC-12.3* RBC-3.67* HGB-11.2 HCT-33.1* MCV-90 MCH-30.5 MCHC-33.8 RDW-13.5 RDWSD-44.0 ___ 07: 40PM LACTATE-3.4* ___ 07: 40PM ALBUMIN-3.7 CALCIUM-8.6 PHOSPHATE-2.5* MAGNESIUM-1.7 ___ 07: 40PM LIPASE-38 ___ 07: 40PM ALT(SGPT)-46* AST(SGOT)-35 ALK PHOS-78 TOT BILI-0.3 ___ 07: 40PM GLUCOSE-143* UREA N-10 CREAT-0.7 SODIUM-135 POTASSIUM-3.3* CHLORIDE-102 TOTAL CO2-15* ANION GAP-18 ___ 01: 33AM LACTATE-0.6 <MEDICATIONS ON ADMISSION> prenatal vitamins <DISCHARGE MEDICATIONS> 1. Cephalexin 500 mg PO Q6H RX *cephalexin 500 mg 1 capsule(s) by mouth q 6 hrs Disp #*48 Capsule 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 hospital for pyelonephritis. You were started on IV antibiotics and remained without a fever. All of your fetal testing have been reassuring. We think it is now safe for you to go home. Please continue to take the antibiotics (keflex ___ mg four times a day for 12 days). 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. ___ was admitted on ___ with pyelonephritis in pregnancy with Tmax of 102.4 on ___. She was treated with IV Ceftriaxone q24hours. Her renal U/S showed mild left hydronephrosis resolves postvoid. On IV antibiotics, she remained afebrile from ___. Her urine cultures from Atrius ___ came back positive for E.Coli >100K, pan sensitive. Fetal survey ultrasounf by ___ MFM: EIF otherwise no abnormality. Patient was counseled by ___ and opted no further testing. Patient remained afebrile for over 48 hours, and deemed stable. She was discharged home with PO keflex ___ mg q6h to complete 14 day course. Patient to follow up with primary ob/gyn.
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11082123-DS-13
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Latex / morphine / Dilaudid <ATTENDING> ___ <CHIEF COMPLAINT> "This pressure is worsening and affecting my quality of life". <MAJOR SURGICAL OR INVASIVE PROCEDURE> Robotic assisted laparoscopic sacrocolpopexy <HISTORY OF PRESENT ILLNESS> Mrs. ___ is a ___ yo Gravida 2 Para 2 who presents today in the office for a consultation requested by Dr. ___ vaginal prolapse. She is complaining of worsening vaginal pressure that is concerning to her. She has gone to pelvic pt and reports some improvement in her labial pain. She feels it about once a week and it is of short duration. She reports no incontinence events. She voids ___ times per day and ___ times per night. She uses no pads per day. She admits to some urgency, she denies any dysuria and reports bladder emptying with interrupted flow. She denies any hematuria, UTI's, kidney stones or pyelonephritis. Mrs. ___ also admits to some vaginal pressure and palpable prolapse. She also admits to constipation/diarrhea. She is sexually active and does experience dyspareunia focused on her left side. She denies any vaginal dryness. She is otherwise without any other significant complaints. <PAST MEDICAL HISTORY> PAST MEDICAL HISTORY: 1. Asthma 2. Allergic rhinitis 3. Low back pain PAST SURGICAL HISTORY 1. Sigmoid resection 2. TVH Anterior and posterior colporrhaphies PAST OB HISTORY G2P2002 Vaginal: 2 PAST GYN HISTORY She is s/p TVH ALLERGIES: dilaudid, latex, morphine MEDICATIONS: albuterol, pulmicort, fluticasone, ambien prn <SOCIAL HISTORY> ___ <FAMILY HISTORY> Her family history is unremarkable for Breast, Ovarian cancer + uncle with ___ cancer. <PHYSICAL EXAM> On day of discharge: afebrile, vital signs stable Gen: NAD CV: RRR Pulm: CTAB, normal work of breathing Abd: soft, nondistended, appropriate TTP, no rebound or guarding <MEDICATIONS ON ADMISSION> The Preadmission Medication list is accurate and complete. 1. Albuterol Inhaler 2 PUFF IH Q6H: PRN sob 2. Budesonide Nasal Inhaler 90 mcg Other bid 3. Fluticasone Propionate NASAL 1 SPRY NU BID 4. Zolpidem Tartrate 5 mg PO QHS: PRN insomnia 5. Loratadine 10 mg PO DAILY 6. Multivitamins 1 TAB PO DAILY <DISCHARGE MEDICATIONS> 1. Albuterol Inhaler 2 PUFF IH Q6H: PRN sob 2. Budesonide Nasal Inhaler 90 mcg Other bid 3. Loratadine 10 mg PO DAILY 4. Acetaminophen 1000 mg PO Q6H 5. Docusate Sodium 100 mg PO BID RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day Disp #*60 Capsule Refills: *1 6. Ibuprofen 600 mg PO Q6H: PRN Pain RX *ibuprofen 600 mg 1 tablet(s) by mouth every six (6) hours Disp #*45 Tablet Refills: *1 7. OxycoDONE (Immediate Release) ___ mg PO Q4H: PRN pain RX *oxycodone 5 mg ___ tablet(s) by mouth every six (6) hours Disp #*30 Tablet Refills: *0 8. Fluticasone Propionate NASAL 1 SPRY NU BID 9. Multivitamins 1 TAB PO DAILY 10. Zolpidem Tartrate 5 mg PO QHS: PRN insomnia <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> Pelvic organ prolapse <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Dear Ms. ___, You were admitted to the gynecology service after your procedure. You have recovered well and the team believes you are ready to be discharged home. Please call Dr. ___ office with any questions or concerns. Please follow the instructions below. General instructions: * Take your medications as prescribed. * Do not drive while taking narcotics. * Take a stool softener such as colace while taking narcotics to prevent constipation. * Do not combine narcotic and sedative medications or alcohol. * Do not take more than 4000mg acetaminophen (APAP) in 24 hrs. * No strenuous activity until your post-op appointment. * No heavy lifting of objects >10 lbs for 6 weeks. * You may eat a regular diet. * You may walk up and down stairs. Incision care: * You may shower and allow soapy water to run over incision; no scrubbing of incision. No bath tubs for 6 weeks. To reach medical records to get the records from this hospitalization sent to your doctor at home, call ___.
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On ___, Ms. ___ was admitted to the gynecology service after undergoing robot-assisted laparoscopic sacrocolpopexy, bilateral salpingoophrectomy and cystoscopy. Please see the operative report for full details. Her post-operative course was uncomplicated. Immediately post-op, her pain was controlled with IV dilaudid and toradol. On post-operative day 1, her urine output was adequate so her foley was removed and she voided spontaneously. Her diet was advanced without difficulty and she was transitioned to percocet and motrin. By post-operative day 1, she was tolerating a regular diet, voiding spontaneously, ambulating independently, and pain was controlled with oral medications. She was then discharged home in stable condition with outpatient follow-up scheduled.
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11082580-DS-14
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> primary low transverse cesarean section pre-eclampsia, severe by BPs post partum hemorrhage <MAJOR SURGICAL OR INVASIVE PROCEDURE> primary low transverse cesarean section <PHYSICAL EXAM> On admission: VITAL SIGNS Weight: 152 BMI: 29.7 BP: 124/80 PHYSICAL EXAMINATION Neuro/Psych: Oriented x3, Affect Normal, NAD. Neck: No masses, Trachea midline, Thyroid normal size, non-tender, no masses or nodules. Nodes: No clavicular/cervical adenopathy, No inguinal adenopathy. Skin: No atypical lesions. Heart: Regular rate and rhythm, No edema or varicosities. Lungs: Clear, Normal respiratory effort. Breasts: No dominant masses, nipple discharge, or lympadenopathy. Abdomen: Non tender, Non distended, No masses, guarding or rebound, No hepatosplenomegally, No hernia. Vulva: Nl hair pattern, no lesions. Bus: Urethra NT, no masses, skein & bartholin glands normal, Urethra meatus central, no prolapse. Vagina: No lesions, well supported, Cystocel absent, Rectocele absent, Bladder non-tender, no masses appreciated. Cervix: No CMT, no lesions, no discharge. Uterus: Small, reg, mobile, NT, Prolapse absent. Adnexa: Small, non-tender, no masses or nodules. Rectal: Nl anus & perineum, No hemorrhoids, Nl NT, no masses. On discharge: Vitals: 24 HR Data (last updated ___ @ 2316) Temp: 99.0 (Tm 99.0), BP: 147/88 (110-147/66-90), HR: 93 (76-93), RR: 18, O2 sat: 99% (98-100), O2 delivery: ra General: NAD, A&Ox3 CV: RRR Lungs: No respiratory distress, CTAB Abd: soft, nontender, fundus firm below umbilicus Incision: clean, dry, intact, no erythema/induration Lochia: minimal Extremities: no calf tenderness, no edema <PERTINENT RESULTS> ___ 10: 55AM BLOOD WBC-25.6* RBC-2.72* Hgb-6.4* Hct-21.1* MCV-78* MCH-23.5* MCHC-30.3* RDW-20.7* RDWSD-55.8* Plt ___ ___ 09: 55AM BLOOD WBC-10.2* RBC-2.63* Hgb-6.1* Hct-20.1* MCV-76* MCH-23.2* MCHC-30.3* RDW-20.3* RDWSD-54.7* Plt ___ ___ 08: 44AM BLOOD WBC-18.4* RBC-3.13* Hgb-7.2* Hct-22.8* MCV-73* MCH-23.0* MCHC-31.6* RDW-20.1* RDWSD-51.9* Plt ___ ___ 02: 43AM BLOOD WBC-17.8* RBC-3.05* Hgb-7.2* Hct-22.6* MCV-74* MCH-23.6* MCHC-31.9* RDW-19.8* RDWSD-51.8* Plt ___ ___ 08: 52PM BLOOD WBC-18.5* RBC-3.50* Hgb-8.1* Hct-25.5* MCV-73* MCH-23.1* MCHC-31.8* RDW-19.5* RDWSD-50.4* Plt ___ ___ 04: 41PM BLOOD WBC-18.7* RBC-3.44* Hgb-8.1* Hct-25.0* MCV-73* MCH-23.5* MCHC-32.4 RDW-19.3* RDWSD-49.4* Plt ___ ___ 10: 47AM BLOOD WBC-21.4* RBC-4.05 Hgb-9.4* Hct-30.2* MCV-75* MCH-23.2* MCHC-31.1* RDW-20.4* RDWSD-53.8* Plt ___ ___ 07: 14AM BLOOD WBC-17.1* RBC-2.94* Hgb-6.2* Hct-20.8* MCV-71* MCH-21.1* MCHC-29.8* RDW-17.3* RDWSD-43.6 Plt ___ ___ 05: 24AM BLOOD WBC-16.8* RBC-4.39 Hgb-9.4* Hct-30.7* MCV-70* MCH-21.4* MCHC-30.6* RDW-17.6* RDWSD-42.4 Plt ___ ___ 12: 31AM BLOOD WBC-9.6 RBC-4.71 Hgb-9.9* Hct-33.0* MCV-70* MCH-21.0* MCHC-30.0* RDW-17.5* RDWSD-42.1 Plt ___ ___ 08: 44AM BLOOD Creat-0.9 ___ 02: 43AM BLOOD Creat-1.1 ___ 08: 52PM BLOOD Creat-1.3* ___ 04: 41PM BLOOD Creat-1.1 ___ 10: 47AM BLOOD Creat-1.1 ___ 05: 24AM BLOOD Creat-1.1 ___ 12: 31AM BLOOD Creat-0.6 ___ 01: 44PM BLOOD Creat-0.7 ___ 08: 52PM BLOOD ALT-8 AST-21 ___ 04: 41PM BLOOD ALT-7 AST-21 ___ 10: 47AM BLOOD ALT-8 AST-24 ___ 05: 24AM BLOOD ALT-9 AST-17 ___ 12: 31AM BLOOD ALT-12 AST-20 ___ 01: 44PM BLOOD ALT-13 AST-25 ___ 02: 43AM BLOOD Mg-4.9* ___ 08: 52PM BLOOD Mg-4.7* ___ 04: 41PM BLOOD Mg-5.4* UricAcd-6.8* ___ 10: 47AM BLOOD Mg-6.9* ___ 10: 43AM BLOOD Calcium-6.8* Phos-5.5* ___ 07: 14AM BLOOD Mg-8.5* ___ 05: 24AM BLOOD Mg-10.6* UricAcd-6.8* ___ 07: 33AM BLOOD Type-ART pO2-115* pCO2-27* pH-7.39 calTCO2-17* Base XS--6 Intubat-NOT INTUBA ___ 07: 33AM BLOOD Glucose-112* Lactate-2.4* Na-130* K-3.8 Cl-105 ___ 07: 33AM BLOOD Hgb-6.3* calcHCT-19 ___ 07: 33AM BLOOD freeCa-1.02* <MEDICATIONS ON ADMISSION> PNV <DISCHARGE MEDICATIONS> 1. Acetaminophen ___ mg PO Q6H: PRN Pain available without prescription 2. Docusate Sodium 100 mg PO BID: PRN Constipation available without prescription RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice a day Disp #*40 Capsule Refills: *1 3. Ferrous Sulfate 325 mg PO BID RX *ferrous sulfate 325 mg (65 mg iron) 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills: *1 4. Ibuprofen 600 mg PO Q6H: PRN Pain RX *ibuprofen 600 mg 1 tablet(s) by mouth every 6 Disp #*30 Tablet Refills: *0 5. Labetalol 400 mg PO Q8H RX *labetalol 200 mg 2 tablet(s) by mouth every eight (8) hours Disp #*84 Tablet Refills: *0 6. NIFEdipine (Extended Release) 30 mg PO DAILY RX *nifedipine 30 mg 1 tablet(s) by mouth every ___ (24) hours Disp #*14 Tablet Refills: *0 7. OxyCODONE (Immediate Release) ___ mg PO Q4H: PRN pain RX *oxycodone 5 mg 1 tablet(s) by mouth every 6 hours Disp #*15 Tablet Refills: *0 <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> primary low transverse cesarean section severe pre-eclampsia anemia and s/p blood transfusion <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> pelvic rest x 6 weeks for postpartum visit keep incision clean and dry no heavy lifting or driving x 2 weeks
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Ms. ___ is a ___ year old G1P0 who underwent a primary low transverse cesarean section on ___ for arrest of dilation. Her pregnancy and post partum course was complicated by severe pre-eclampsia by BPs, acute kidney injury of likely pre-renal origin and post partum hemorrhage. Please see operative note for full details. Regarding her post partum hemorrhage, her estimated blood loss was 2.2 L secondary to atony. She required intraoperative pressors and received pitocin, methergine x1, hemabate x1, TXA. Her hematocrit was trended and it was noted to fall from 30.7 at ___ to 19 at 0735 ___. She was thus transfused 2 units of packed red blood cells. She had an appropriate rise in hematocrit to 30.2. Her coags were noted to be within normal limits. She was started on PO iron. Her hematocrit was then trended as follows: 25.5 (___ -> 22.6 (0245 ___ -> 22.8 ___ AM) -> 20.1 ___ AM) -> 21.1 (___). Given stable hematocrit and normal urine output with no tachycardia, no further transfusion was recommended. Regarding her severe pre-eclampsia by BPs, she received 40mg labetalol on ___ and ___ for severe range BPs. She received magnesium for 24 hours postpartum. Of note, her magnesium was initially discontinued intraoperatively for magnesium toxicity. She received calcium 1g gluconate and 2g IV Calcium intraop. Patient's pregnancy induced hypertension labs were within normal limits on ___, her urine Protein/creatinine ratio was 0.8. For her BPs, she was started on Labetalol 200mg q8h from ___ to ___. On ___, patient's labetalol was increased to 400mg to Q8H given rising BPs. She subsequently had severe range sustained BPs in the evening so she was given nifedipine 10mg as well as 20mg PO Lasix for 1+ pitting edema to knees bilaterally. For further BP control, patient was also started on nifedipine 30mg XR on ___. Regarding her acute kidney injury, her creatinine increased from 0.6 to 1.3 on ___. This was attributed to pre-renal causes. Patient was repleted with IVF hydration and previously mentioned blood transfusion. Her creatinine was then trended as follows: Cr 0.6 (___) -> 1.3 (___ -> 1.1 (0245 ___ -> 0.9 ___ AM). Given improving creatinine, it was no longer trended. By post partum day 5, patient's vitals were within normal limits. She was ambulating, voiding, eating without nausea or vomiting. Her pain was well controlled. She was then discharged home with close follow up.
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| 639
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11082580-DS-15
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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 <PHYSICAL EXAM> <PHYSICAL EXAM> General: NAD, A&Ox3 Lungs: No respiratory distress Abd: soft, non-tender, fundus firm below umbilicus Incision: clean/dry/intact, tender to palpation superior to incision in midline, 5cm area of induration on left side of incision, no surrounding erythema or drainage Lochia: minimal Extremities: no calf tenderness, no edema <PERTINENT RESULTS> Labs on Admission: ___ 05: 48AM BLOOD WBC-13.3* RBC-3.09* Hgb-7.4* Hct-24.4* MCV-79* MCH-23.9* MCHC-30.3* RDW-20.6* RDWSD-57.8* Plt ___ ___ 05: 48AM BLOOD Neuts-94.5* Lymphs-2.5* Monos-1.8* Eos-0.1* Baso-0.2 NRBC-0.3* Im ___ AbsNeut-12.55* AbsLymp-0.33* AbsMono-0.24 AbsEos-0.01* AbsBaso-0.02 ___ 05: 48AM BLOOD ___ PTT-34.0 ___ ___ 05: 48AM BLOOD Glucose-101* UreaN-7 Creat-0.5 Na-143 K-3.8 Cl-115* HCO3-14* AnGap-13 ___ 05: 48AM BLOOD ALT-23 AST-29 AlkPhos-140* TotBili-0.9 ___ 05: 48AM BLOOD Lipase-19 ___ 05: 48AM BLOOD cTropnT-0.02* ___ 05: 48AM BLOOD Albumin-3.0* Calcium-7.7* Phos-2.5* Mg-1.7 ___ 05: 48AM BLOOD Lactate-1.3 Relevant Labs: ___ 06: 05AM BLOOD WBC-10.7* RBC-2.86* Hgb-6.9* Hct-22.4* MCV-78* MCH-24.1* MCHC-30.8* RDW-20.3* RDWSD-57.4* Plt ___ ___ 06: 05AM BLOOD Neuts-76.7* Lymphs-12.7* Monos-6.8 Eos-1.4 Baso-0.4 NRBC-0.7* Im ___ AbsNeut-8.25* AbsLymp-1.36 AbsMono-0.73 AbsEos-0.15 AbsBaso-0.04 ___ 06: 05AM BLOOD Plt ___ ___ 06: 05AM BLOOD ___ PTT-33.3 ___ ___ 06: 05AM BLOOD Glucose-89 UreaN-12 Creat-0.6 Na-143 K-3.9 Cl-112* HCO3-20* AnGap-11 ___ 08: 45AM BLOOD WBC-8.7 RBC-3.09* Hgb-7.3* Hct-24.0* MCV-78* MCH-23.6* MCHC-30.4* RDW-20.5* RDWSD-57.3* Plt ___ <MEDICATIONS ON ADMISSION> - Augmentin - Iron - Labetalol 400 mg TID - Nifedipine XL 30 mg daily <DISCHARGE MEDICATIONS> 1. Acetaminophen ___ mg PO Q6H: PRN Mild Pain available without prescription 2. Amoxicillin-Clavulanic Acid ___ mg PO Q12H post-operative fever Duration: 10 Days prescription has been sent to your pharmacy 3. Ferrous Sulfate 325 mg PO DAILY available without prescription 4. Ibuprofen 600 mg PO Q6H: PRN Moderate Pain lower doses available without prescription 5. Labetalol 400 mg PO TID 6. NIFEdipine (Extended Release) 30 mg PO DAILY <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> s/p primary low transverse cesarean section fever pelvic fluid collection severe pre-eclampsia <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> pelvic rest x 6 weeks until postpartum visit keep incision clean and dry no heavy lifting or driving x 2 weeks
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Ms. ___ was readmitted on ___ with a fever concerning for superinfected hematoma versus evolving pelvic abscess. Patient had a TVUS on admission showing heterogeneous, predominantly hypoechoic contents are seen within the endometrium and endocervical canal without associated vascularity and a small amount of fluid within the patient is C-section defect. She also had a CT chest, abdomen, and pelvis showing fluid at the low transverse C-section incision scar in the anterior wall of the uterus measuring 2.8 x 5.3 x 1.3 cm that may reflect an evolving hematoma or developing collection at the incision site, superinfection cannot be excluded. She was started on IV Zosyn on admission but was then transitioned to IV cefepime and flagyl per AST recommendations. She had a flu swab that was negative. ___ was consulted regarding the collection, however, felt this collection was not amendable to drainage. Infectious disease was then consulted ___ and recommended transitioning to PO Augmentin 875/125 mg BID for 10 days. Patient was continued on her Labetalol 400mg TID and 30mg Nifedipine for her pre-eclampsia. Her blood pressures were within normal limits for the duration of her hospitalization. On ___, patient was discharged in stable condition with plan for PO Augmentin and follow up scheduled.
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| 293
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11084261-DS-4
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Penicillins / Latex / Statins-Hmg-Coa Reductase Inhibitors / Enalapril / Nifedipine / Norvasc / Percocet <ATTENDING> ___. <CHIEF COMPLAINT> post-menopausal bleeding <MAJOR SURGICAL OR INVASIVE PROCEDURE> total laparoscopic hysterectomy, bilateral salpingo-oophorectomy, cystoscopy <HISTORY OF PRESENT ILLNESS> ___ Je___'s Witness who presented with postmenopausal bleeding. She had undergone a hysteroscopy D and C on ___ which was notable for an endometrial polyp, and final pathology revealed foci of endometrial intraepithelial neoplasia in a background of atrophic endometrium. The curettings also showed further EIN. The recomendation was to proceed with surgical management <PAST MEDICAL HISTORY> PMHx: asthma, HTN, T2DM, osteoarthritis, right leg tumor (enchondroma/benign), OSA PSHx: tonsils, excisions breast cyst, repair rotator cuff x2 Ob/gyn hx: G3P2 with 3 vaginal deliveries (one IUFD). LMP ___, no hx abnl Pap, not sexually active, no hx HRT, known fibroid uterus <SOCIAL HISTORY> ___ <FAMILY HISTORY> denies family hx of ovarian, breast, colon, uterine cancers. multiple members with HTN, diabetes, heart disease <PHYSICAL EXAM> On day of discharge: AVFSS No acute distress CV: regular rate and rhythm Pulm: clear to auscultation bilaterally Abd: soft, appropriately tender, nondistended, incision clean/dry/intact, no rebound/guarding ___: nontender, nonedematous <PERTINENT RESULTS> ___ 07: 22AM BLOOD WBC-7.9 RBC-3.95* Hgb-9.3* Hct-29.0* MCV-73* MCH-23.5* MCHC-32.0 RDW-15.6* Plt ___ ___ 02: 50PM BLOOD WBC-8.8 RBC-3.77* Hgb-8.6* Hct-27.6* MCV-73* MCH-23.0* MCHC-31.4 RDW-15.5 Plt ___ ___ 09: 30PM BLOOD WBC-8.3 RBC-3.39* Hgb-8.0* Hct-24.6* MCV-72* MCH-23.5* MCHC-32.5 RDW-15.9* Plt ___ ___ 06: 55AM BLOOD WBC-7.6 RBC-3.07* Hgb-7.1* Hct-22.3* MCV-72* MCH-23.0* MCHC-31.8 RDW-15.7* Plt ___ ___ 09: 20AM BLOOD WBC-8.9 RBC-2.99* Hgb-7.1* Hct-21.8* MCV-73* MCH-23.7* MCHC-32.5 RDW-15.9* Plt ___ ___ 01: 00PM BLOOD WBC-10.9 RBC-3.21* Hgb-7.3* Hct-23.3* MCV-73* MCH-22.8* MCHC-31.4 RDW-15.4 Plt ___ ___ 05: 20PM BLOOD WBC-10.0 RBC-2.98* Hgb-6.9* Hct-21.6* MCV-72* MCH-23.3* MCHC-32.2 RDW-15.8* Plt ___ ___ 01: 45AM BLOOD WBC-7.8 RBC-2.68* Hgb-6.2* Hct-19.4* MCV-72* MCH-23.3* MCHC-32.3 RDW-15.9* Plt ___ ___ 11: 00AM BLOOD Hgb-6.4* Hct-21.1* ___ 07: 35AM BLOOD WBC-5.8 RBC-2.82* Hgb-6.5* Hct-21.0* MCV-74* MCH-23.2* MCHC-31.2 RDW-16.5* Plt ___ ___ 07: 55AM BLOOD WBC-6.4 RBC-3.02* Hgb-7.3* Hct-22.2* MCV-74* MCH-24.1* MCHC-32.6 RDW-17.1* Plt ___ ___ 12: 15AM BLOOD ___ PTT-25.1 ___ ___ 09: 20AM BLOOD ___ PTT-29.7 ___ ___ 12: 15AM BLOOD ___ ___ 07: 22AM BLOOD Glucose-166* UreaN-16 Creat-0.9 Na-140 K-3.9 Cl-102 HCO3-27 AnGap-15 ___ 09: 30PM BLOOD Glucose-195* UreaN-15 Creat-0.8 Na-138 K-3.3 Cl-99 HCO3-28 AnGap-14 ___ 06: 55AM BLOOD Glucose-167* UreaN-18 Creat-1.1 Na-136 K-3.4 Cl-98 HCO3-30 AnGap-11 ___ 09: 20AM BLOOD Glucose-158* UreaN-19 Creat-1.1 Na-140 K-3.4 Cl-101 HCO3-29 AnGap-13 ___ 07: 35AM BLOOD Glucose-107* UreaN-8 Creat-0.8 Na-140 K-3.5 Cl-103 HCO3-31 AnGap-10 ___ 09: 20AM BLOOD LD(LDH)-139 TotBili-0.5 DirBili-0.2 IndBili-0.3 ___ 07: 22AM BLOOD Calcium-8.8 Phos-3.4 Mg-1.4* ___ 06: 55AM BLOOD Calcium-9.1 Phos-2.6* Mg-2.1 ___ 09: 20AM BLOOD Calcium-8.7 Phos-2.3* Mg-2.7* Iron-55 ___ 07: 35AM BLOOD Calcium-9.2 Phos-1.9* Mg-1.6 ___ 02: 50PM BLOOD cTropnT-<0.01 ___ 09: 30PM BLOOD cTropnT-<0.01 ___ 09: 20AM BLOOD calTIBC-225* ___ Ferritn-216* TRF-173* ___ 12: 34PM URINE RBC-1 WBC-5 Bacteri-NONE Yeast-NONE Epi-3 ___ 12: 34PM URINE Blood-NEG Nitrite-NEG Protein-TR Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-4* pH-8.5* Leuks-NEG ___ 12: 34PM URINE Color-Yellow Appear-Clear Sp ___ CTA Chest on ___ IMPRESSION: 1. No pulmonary embolism or aortic dissection. 2. Dilatation of the ascending thoracic aorta has increased since ___. 3. Bronchiectatic changes are seen at the bilateral bases, with adjacent atelectasis versus scarring. An additional focus of atelectasis is seen within the right upper lobe, tracking along the bronchopulmonary bundle. 4. Multiple hepatic cysts. 5. Small amount of perihepatic ascites. Pneumoperitoneum from recent surgery. CTA Abd/Pelvis on ___ 1. Hemo peritoneum with a moderate amount of pelvic, perihepatic and perisplenic hemorrhage. No evidence of active arterial extravasation. Focus of high density within the left gonadal vein may represent contrast and a possible source of the venous bleeding or thrombus. 2. Multiple stable hepatic hypodensities, some of which are cysts and others are too small to characterize. 3. Bibasilar atelectasis. <MEDICATIONS ON ADMISSION> chlorthalidone, clonidine, lisinopril, losartan, rosuvastatin <DISCHARGE MEDICATIONS> 1. Chlorthalidone 50 mg PO DAILY 2. CloniDINE 0.2 mg PO BID 3. Docusate Sodium 100 mg PO BID RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice a day Disp #*60 Capsule Refills: *3 4. HYDROmorphone (Dilaudid) ___ mg PO Q4H: PRN pain RX *hydromorphone [Dilaudid] 2 mg ___ tablet(s) by mouth every four (4) hours Disp #*40 Tablet Refills: *0 5. Lisinopril 40 mg PO DAILY 6. Losartan Potassium 100 mg PO DAILY 7. Rosuvastatin Calcium 5 mg PO QPM 8. Ascorbic Acid ___ mg PO TID RX *ascorbic acid ___ mg 1 tablet(s) by mouth three times daily Disp #*90 Tablet Refills: *3 9. Cyanocobalamin 50 mcg PO DAILY RX *cyanocobalamin (vitamin B-12) [Vitamin B-12] 50 mcg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills: *1 10. Epoetin Alfa 40,000 UNIT SC QMON anemia RX *epoetin alfa [Epogen] 20,000 unit/mL 2 mL SC weekly Disp #*8 Milliliter Refills: *0 11. Ferrous Sulfate 325 mg PO TID RX *ferrous sulfate 325 mg (65 mg iron) 1 tablet(s) by mouth three times daily Disp #*90 Tablet Refills: *3 12. FoLIC Acid 1 mg PO DAILY RX *folic acid 1 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills: *3 13. MetFORMIN (Glucophage) 500 mg PO DAILY 14. Polyethylene Glycol 17 g PO DAILY: PRN constipation RX *polyethylene glycol 3350 [Miralax] 17 gram/dose 1 powder(s) by mouth daily Refills: *3 <DISCHARGE DISPOSITION> Extended Care Facility: ___ <DISCHARGE DIAGNOSIS> endometrial cancer 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 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. * Leave your steri-strips on. If they are still on after ___ days from surgery, you may remove them. To reach medical records to get the records from this hospitalization sent to your doctor at home, call ___. Call your doctor at ___ for: * fever > 100.4 * severe abdominal pain * difficulty urinating * vaginal bleeding requiring >1 pad/hr * abnormal vaginal discharge * redness or drainage from incision * nausea/vomiting where you are unable to keep down fluids/food or your medication * chest pain or difficulty breathing * onset of any concerning symptoms
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Ms. ___ was admitted to the gynecologic oncology service after undergoing total laparoscopic hysterectomy, bilateral salpingo-oophorectomy, cystoscopy for EIN. 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 post-operative course was complicated by acute blood loss anemia and unstable blood volume in the setting of being a ___s Witness who does not accept blood products. She initially received IV iron and was monitored closely on telemetry and with serial CBCs. Her hematocrit continued to drift down to a nadir of 19.4 on POD # 3 at which point she had a CTA abdomen/pelvis to evaluate for any active bleeding amenable to possible ___ embolization. Her CTA showed hemoperitoneum without active extravasation and thus no ___ intervention was warrented. She continued to be hemodynamically stable and her hematocrit remained stable at ___ so no further operative intervention was warrented. A hematology consult was obtained to help manage her anemia and on POD # 3 she was started on epoetin, asorbic acid and ferrous sulfate. On POD # 1 she had a transient episode of chest pressure and an O2 requirement thought likely to be due to her anemia given that she had a normal EKG, negative troponins and a CTA chest without evidence of pulmonary embolus. On POD # 5 she complained of urinary frequency and malaise. A UA and Urine culture were sent. Her UA was negative and her urine culture grew mixed bacterial flora likely due to skin contamination. After she was determined to be hemodynamically stable, her diet was advanced without difficulty and she was transitioned to PO tylenol and dilaudid for pain. Her urine output was adequate so her Foley catheter was removed and she voided spontaneously. She was followed by ___ during her admission who recommended discharge to a rehab facility. For her type 2 diabetes she was continued on metformin once taking PO and for her hypertension she continued on her home antihypertensives. By post-operative day 6, she had a stable hematocrit, was tolerating a regular diet, voiding spontaneously, ambulating independently, and her pain was controlled with oral medications. She was then discharged to rehab in stable condition with outpatient follow-up scheduled.
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11084812-DS-18
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Patient recorded as having No Known Allergies to Drugs <ATTENDING> ___. <CHIEF COMPLAINT> RLQ abdominal pain <MAJOR SURGICAL OR INVASIVE PROCEDURE> none <HISTORY OF PRESENT ILLNESS> consulted regarding this ___ yo G0, LMP ___ who presents to the ED with RLQ pain. The patient states that her pain began ___ at 0200. She states that the pain is sharp and radiates into her R leg. It is somewhat positional and is worse when she is standing or walking and better when she lies on her left side. She denies N/V and has been tol PO. She states that the has very irregular periods. She usually has a period every three to six months. She recently had a period ___. She denies const or diarrhea. <PAST MEDICAL HISTORY> # Pulmonary embolus in ___. CTA showed central filling defect in the right lower lobe pulmonary artery suspicious for PE in ___. S/p treatment with coumadin. # Probable left calf DVT, believed secondary to oral contraceptive. # Stage I hypertension. # History of pseudotumor cerebri. # Morbid obesity. # Multiple burn wounds from childhood burn injury. <SOCIAL HISTORY> ___ <FAMILY HISTORY> No history of clotting disorders. Father has history of hypertension. Mother has history of gastritis and possible rheumatoid arthritis. There is no known history of SLE or thyroid disorders. <PHYSICAL EXAM> 98.7 132 151/76 20 Uncomfortable Clear RRR No CVAT Obese, RLQ tenderness to deep palp without rebound or guarding. Pelvic: external genitalia, vaginal mucosa and cx w/o gross abn. There is no cmt, limited exam ___ body habitus. <PERTINENT RESULTS> ___ 07: 00AM WBC-8.1 RBC-4.05* HGB-11.4* HCT-33.9* MCV-84 MCH-28.2 MCHC-33.6 RDW-15.3 ___ 07: 00AM PLT COUNT-384 ___ 03: 35AM WBC-8.7 RBC-4.31 HGB-11.8* HCT-36.1 MCV-84 MCH-27.3 MCHC-32.6 RDW-15.0 ___ 03: 35AM NEUTS-75.5* LYMPHS-16.3* MONOS-3.0 EOS-4.8* BASOS-0.3 ___ 03: 35AM PLT COUNT-426 ___ 03: 35AM SED RATE-75* ___ 11: 55AM URINE COLOR-Yellow APPEAR-Clear SP ___ ___ 11: 55AM URINE BLOOD-SM NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG ___ 11: 55AM URINE ___ BACTERIA-RARE YEAST-NONE ___ 10: 55AM COMMENTS-GREEN TOP ___ 10: 55AM LACTATE-2.2* ___ 10: 40AM GLUCOSE-115* UREA N-10 CREAT-1.0 SODIUM-135 POTASSIUM-4.6 CHLORIDE-102 TOTAL CO2-22 ANION GAP-16 ___ 10: 40AM estGFR-Using this ___ 10: 40AM WBC-9.2 RBC-4.32 HGB-11.9* HCT-36.0 MCV-83 MCH-27.5 MCHC-33.0 RDW-15.5 ___ 10: 40AM NEUTS-76.8* LYMPHS-15.4* MONOS-2.6 EOS-4.9* BASOS-0.3 ___ 10: 40AM PLT COUNT-394 ___ 10: 40AM ___ PTT-25.0 ___ <MEDICATIONS ON ADMISSION> cefpodoxime for PNA Flovent <DISCHARGE MEDICATIONS> 1. Cefpodoxime 100 mg Tablet Sig: Two (2) Tablet PO Q12H (every 12 hours) for 2 days. <DISCHARGE DISPOSITION> Home With Service Facility: ___ <DISCHARGE DIAGNOSIS> right lower quadrant abdominal pain bilateral pneumonia tachycardia of unknown etiology <DISCHARGE CONDITION> stable <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> please call your doctor if you have increasing abdominal pain unrelieved by medications, nausea/vomiting, fever (temperature greater than 101), chest pain, shortness of breath or any other concerns
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Ms. ___ was admitted for right lower quadrant abdominal pain concerning for ovarian torsion. In the ED, she had a pelvic ultrasound which showed normal-sized symmetric ovaries bilaterally with normal blood flow to both. However, she was admitted for pain control given her significant pain. Her RLQ abdominal pain quickly resolved and the patient had no clinical evidence of torsion as she had no fever, nausea, vomiting, benign abdominal exam and stable WBC of 11 with a stable Hct of 34. Her heart rate was noted to be high- 110's to 130's since her admission. Although she was asymptomatic, with good O2 sats, a CTA was performed in the ED which was negative for PE. Given her tachycardia and recent admission to the medicine service for bilateral pneumonias, a medicine consultation was obtained for the tachycardia. The medicine team did not think that a repeat CTA was necessary and her tachycardia was likely secondary to her being deconditioned and her recent pneumonia. The patient's prelim blood cx from the ED was reported positive for coag negative staph-given the patient clinically improved with no fever or WBC or any other clinical evidence of infection, this was thought to be a contaminant. Another set of blood cx was done during her stay which will be followed up by her PCP. The patient was discharged home on HD #2 in stable condition. The medicine team recommended an echocardiogram as well as a physical therapy consultation as an outpatient.
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11084812-DS-44
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Miralax / Hydrochlorothiazide / Codeine / Benadryl <ATTENDING> ___. <CHIEF COMPLAINT> abnormal uterine bleeding <MAJOR SURGICAL OR INVASIVE PROCEDURE> hysteroscopy, dilation and curettage, colposcopy, endometrial biopsy, cervical biopsy, Mirena IUD placement <HISTORY OF PRESENT ILLNESS> This is a ___ gravida 0 with a history of PCOS and morbid obesity who has always had irregular menses, but developed abnormal uterine bleeding in ___ when she started bleeding on and off for the entire month. She is unsure what changed regarding her medical history but was seen in the office in ___. An endometrial biopsy at that time was insufficient for diagnosis with scant fragments of benign endocervical epithelium. Pap that day was also unsatisfactory for evaluation due to insufficient cellularity. She had a pelvic ultrasound performed on ___ which revealed an anteverted uterus measuring 8.3 x 4.7 x 4.9 cm. The endometrium was 8 mm. The ovaries were normal. There was an intramural fibroid in the left myometrium measuring 2.5 x 2.7 x 2.5 cm and no pelvic free fluid. An endometrial biopsy on ___ was again attempted and this revealed inactive endometrium with focal stromal breakdown and rare fragments of benign endocervix. Pap test repeated on that day revealed atypical glandular cells of uncertain significance. She was counseled that regarding her morbid obesity, further workup was required for both her endometrial bleeding as well as the atypical glandular cells. <PAST MEDICAL HISTORY> 1. CARDIAC RISK FACTORS: Diabetes, Hypertension 2. CARDIAC HISTORY: - ___ with preserved EF, multiple hospitalizations for dyspnea responsive to diuresis 3. OTHER PAST MEDICAL HISTORY: - ___ Antibody Syndrome, on Mycophenolate Mofetil and Methylprednisolone - Interstitial lung disease (per notes, prior CT scans showing sarcoid like picture) - Diabetes mellitus type II not on insulin - Morbid obesity - multiple DVTs/PEs, on lifelong warfarin - PCOS - Sinus tachycardia - OSA on BiPAP - s/p severe burn as an infant w/ multiple skin grafts <SOCIAL HISTORY> ___ <FAMILY HISTORY> - Father: MI, CVA, HTN - Mother: OA - ___: CAD, died of MIs - 7 siblings: All healthy - No history of clotting disordres <PHYSICAL EXAM> On day of discharge Gen: morbidly obese woman in NAD, comfortable CV: RRR Lungs: CTA ABD: obese, NT Ext: obese GU: minimal VB <MEDICATIONS ON ADMISSION> Medications - Prescription ALENDRONATE - alendronate 70 mg tablet. 1 Tablet(s) by mouth weekly BIPAP - . as directed ___ with 4L of 02 - (Prescribed by Other Provider: ___ at d/c) CEVIMELINE - cevimeline 30 mg capsule. One capsule(s) by mouth 3 times a day CITALOPRAM - citalopram 20 mg tablet. 1 Tablet(s) by mouth qday HEPARIN - 10 unit/mL . ___ cc per port today 5cc/100u/cc per venous team protocol IBUPROFEN - ibuprofen 600 mg tablet. 1 tablet by mouth twice a day as needed for pain - (Prescribed by Other Provider: ___ ECF d/c med list) KETOCONAZOLE - ketoconazole 2 % shampoo. Lather hair, leave for 5 minutes, rinse Twice weekly (or weekly if too difficult) METFORMIN - metformin ER 500 mg tablet,extended release 24 hr. 1 tablet extended release 24 hr(s) by mouth twice a day - (Prescribed by Other Provider: during ___ hospitalization) METHYLPREDNISOLONE [MEDROL] - Medrol 4 mg tablet. 1 and a half tablet(s) by mouth daily for 2 weeks, then one daily - (Dose adjustment - no new Rx) METOPROLOL SUCCINATE - metoprolol succinate ER 100 mg tablet,extended release 24 hr. 1 tablet extended release 24 hr(s) by mouth twice a day - (Prescribed by Other Provider: rehab DC) MISOPROSTOL - misoprostol 200 mcg tablet. 2 Tablet(s) by mouth once take 3 hours before surgery. place one tablet in each cheek and allow to dissolve. MORPHINE - morphine 15 mg tablet. 1 tablet(s) by mouth prn - (Prescribed by Other Provider) MYCOPHENOLATE MOFETIL - mycophenolate mofetil 500 mg tablet. 3 Tablet(s) by mouth twice a day OMEPRAZOLE - omeprazole 20 mg capsule,delayed release. 1 capsule,delayed ___ by mouth twice a day - (Prescribed by Other Provider) ONDANSETRON HCL - ondansetron HCl 4 mg tablet. 1 tablet by mouth every 8 hours as needed for nausea - (Dose adjustment - no new Rx) PLEASE ACCESS PORT FOR BLOOD DRAW - . today once a day POTASSIUM CHLORIDE [KLOR-CON 10] - Klor-Con 10 mEq tablet,extended release. THREE tablet extended release(s) by mouth every day - (Prescribed by Other Provider; Dose adjustment - no new Rx) SODIUM CHLORIDE 0.9 % [NORMAL SALINE FLUSH] - Normal Saline Flush injection syringe. 1 dose per port today SULFAMETHOXAZOLE-TRIMETHOPRIM - sulfamethoxazole 800 mg-trimethoprim 160 mg tablet. 1 tablet by mouth ___, and ___ - (Prescribed by Other Provider) TORSEMIDE - torsemide 100 mg tablet. 1 tablet(s) by mouth eevry am - (Prescribed by Other Provider; Dose adjustment - no new Rx) WARFARIN - warfarin 1 mg tablet. 1 tablet by mouth ud WARFARIN [COUMADIN] - Coumadin 5 mg tablet. 1 tablet(s) by mouth daily, in addition to 1 mg for a total of 6 mg Medications - OTC ACETAMINOPHEN - acetaminophen ER 650 mg tablet,extended release. 1 tablet by mouth every four (4) hours as needed for pain or fever greater than ___ F - (Prescribed by Other Provider: ___ ECF d/c med list) CALCIUM CARBONATE [TUMS] - Tums 200 mg calcium (500 mg) chewable tablet. 2 Tablet(s) by mouth twice a day - (Prescribed by Other Provider) CHOLECALCIFEROL (VITAMIN D3) [VITAMIN D3] - Vitamin D3 400 unit capsule. 2 Capsule(s) by mouth DAILY (Daily) FERROUS SULFATE - ferrous sulfate 325 mg (65 mg iron) tablet. 1 tablet(s) by mouth 10AM and 6 ___ FOLIC ACID - folic acid 1 mg tablet. 1 tablet(s) by mouth daily - (OTC) LANCETS [ONE TOUCH ULTRASOFT LANCETS] - One Touch UltraSoft Lancets. Use as directed for blood sugar monitoring up to four times a day and as needed MULTIVITAMIN - multivitamin capsule. 1 Capsule(s) by mouth qday SIMETHICONE - simethicone 80 mg chewable tablet. 1 Tablet(s) by mouth four times a day as needed for gas <DISCHARGE MEDICATIONS> 1. Acetaminophen 325-650 mg PO Q6H: PRN pain RX *acetaminophen 500 mg ___ tablet(s) by mouth q6h: prn Disp #*20 Tablet Refills: *0 2. cevimeline 30 mg oral TID 3. Citalopram 20 mg PO DAILY 4. Heparin Flush (10 units/ml) 5 mL IV DAILY and PRN, line flush 5. Heparin Flush (100 units/ml) 5 mL IV PRN DE-ACCESSING port 6. Ibuprofen 600 mg PO Q6H: PRN pain take with food RX *ibuprofen 600 mg 1 tablet(s) by mouth q6h: prn Disp #*20 Tablet Refills: *0 7. MetFORMIN XR (Glucophage XR) 500 mg PO BID 8. Methylprednisolone 4 mg PO DAILY 9. Metoprolol Succinate XL 100 mg PO DAILY 10. Morphine Sulfate ___ 15 mg PO Q8H: PRN pain 11. Mycophenolate Mofetil 1500 mg PO BID 12. Omeprazole 40 mg PO DAILY 13. Potassium Chloride 10 mEq PO TID Duration: 24 Hours 14. Sulfameth/Trimethoprim DS 1 TAB PO ___ 15. Torsemide 100 mg PO DAILY 16. Warfarin 6 mg PO DAILY16 <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> abnormal uterine bleeding <DISCHARGE CONDITION> stable <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Dear Ms. ___, You were admitted to the gynecology service after your surgery. You recovered well and are ready to be discharged home. Please follow these instructions: General instructions: * Take your medications as prescribed. * Do not take more than 4000mg acetaminophen (APAP) in 24 hrs. * No strenuous activity until your post-op appointment. * Nothing in the vagina (no tampons, no douching, no sex) for 4 weeks. * No heavy lifting of objects >10 lbs for 6 weeks. * You may eat a regular diet. * You may walk up and down stairs. Call your doctor for: * fever > 100.4 * 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. ___ underwent the procedures listed above. Due to her multiple comarbidities she was admitted for observation overnight. She tolerated the procedure well, remained stable and recovered well. Her pain was controlled with PO pain medication, voiding spontaneously and tolerating a regular diet. On post operative day #1 she was discharged home with plans to follow up.
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11084812-DS-48
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Miralax / Hydrochlorothiazide / Codeine / Benadryl / heparin / lisinopril <ATTENDING> ___ <CHIEF COMPLAINT> Abnormal pap smear, cervical dysplasia <MAJOR SURGICAL OR INVASIVE PROCEDURE> LEEP <PHYSICAL EXAM> Discharge physical exam Vitals: VSS Gen: NAD, A&O x 3 CV: RRR Resp: no acute respiratory distress Abd: soft, appropriately tender, no rebound/guarding Ext: no TTP <PERTINENT RESULTS> ___ 07: 21AM BLOOD ___ PTT-62.5* ___ <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 take more than 4000mg acetaminophen (APAP) in 24 hrs. * Nothing in the vagina (no tampons, no douching, no sex) for 2 weeks. * You may eat a regular diet. * You may walk up and down stairs. Call your doctor for: * fever > 100.4F * severe abdominal pain * difficulty urinating * vaginal bleeding requiring >1 pad/hr * abnormal vaginal discharge * redness or drainage from incision * nausea/vomiting where you are unable to keep down fluids/food or your medication To reach medical records to get the records from this hospitalization sent to your doctor at home, call ___.
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On ___, Ms. ___ was admitted to the gynecology service after undergoing a LEEP and endocervical curettage. Please see the operative report for full details. She was admitted for observation overnight given her multiple medical comorbidities. *) Post-operative: Her post-operative course was uncomplicated. Immediately post-op, her pain was controlled with PO acetaminophen prn. Her diet was advanced without difficulty, and she denied any nausea/vomiting. She was able to void spontaneously on post-operative day #0. *) DVT/PE: Pt was continued on prophylactic lovenox 60mg BID while hospitalized. She also had pneumoboots bilaterally for mechanical prophylaxis. She was restarted on her home dose of Coumadin on post-operative day #1. *) Diastolic congestive heart failure, HTN: Pt was continued on her home dose of torsemide, metoprolol, and losartan. *) Interstitial lung disease, obstructive sleep apnea, asthma: Pt was continued on her home medications, used her CPAP/Bipap, and was monitored on telemetry. She did not have any evidence of respiratory distress and had oxygen saturations in the high ___ on room air prior to discharge. *) T2DM: Pt was maintained on an insulin sliding scale on post-operative day #0. Her fingersticks blood glucose measurements ranged from 177-201. 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. FLUoxetine 10 mg PO DAILY 2. GlipiZIDE XL 2.5 mg PO DAILY 3. liraglutide 1.8 mg subcutaneous DAILY 4. Losartan Potassium 25 mg PO DAILY 5. Metoprolol Succinate XL 100 mg PO DAILY 6. Torsemide 10 mg PO DAILY 7. Warfarin 6 mg PO DAILY Duration: 1 Dose Discharge Disposition: Home Discharge Diagnosis: Cervical dysplasia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Followup Instructions: ___
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11086653-DS-19
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> primary C-section, blood transfusion <MAJOR SURGICAL OR INVASIVE PROCEDURE> primary C-section blood transfusion <PERTINENT RESULTS> ___ 09: 45AM WBC-10.3* RBC-4.19# HGB-10.9* HCT-34.5 MCV-82# MCH-26.0# MCHC-31.6* RDW-15.6* RDWSD-46.7* ___ 09: 45AM PLT COUNT-312 <MEDICATIONS ON ADMISSION> albuterol, fluticasone, cyclobenzaprine <DISCHARGE MEDICATIONS> 1. Ibuprofen 600 mg PO Q6H: PRN Pain - Moderate RX *ibuprofen 600 mg 1 tablet(s) by mouth four times a day Disp #*40 Tablet Refills: *1 2. OxyCODONE (Immediate Release) ___ mg PO Q4H: PRN pain RX *oxycodone 5 mg 1 tablet(s) by mouth four times a day Disp #*30 Tablet Refills: *0 <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> arrest of labor, cephalopelvic disproportion post partum hemorrage <DISCHARGE CONDITION> good <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> rest. no heavy lifting, exercise baths for 4 weeks
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On ___ Ms. ___ was admitted to Labor & Delivery. She underwent a low transverse cesarean section. Pre-operatively, her Hct was 34.5, intra-operatively it was 30.4 and she was given 2 units packed red blood cells and 1 unit FFP. Hct stabilized to 28.2. Her post-operative course was uncomplicated. By postpartum day 3, she was tolerating a regular diet, ambulating independently, and pain was controlled with oral medications. She was afebrile with stable vital signs. She was then discharged home in stable condition with postpartum outpatient follow-up scheduled.
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11087209-DS-18
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Penicillins <ATTENDING> ___ <CHIEF COMPLAINT> UTERINE PROLAPSE <MAJOR SURGICAL OR INVASIVE PROCEDURE> EXTENSIVE LYSIS OF ADHESIONS;ROBOTIC ASSISTED SUPRACERVICAL HYSTERECTOMY, BILATERAL SALPINGO-OOPHORECTOMY, SACROCERVICOPEXY WITH SYNTHETIC GRAFT AND CYSTOSCOPY <PHYSICAL EXAM> PHYSICAL EXAM AT DISCHARGE -========= 24 HR Data (last updated ___ @ 517) Temp: 98.3 (Tm 98.7), BP: 99/61 (99-142/60-75), HR: 84 (84-97), RR: 18, O2 sat: 97% (92-97), O2 delivery: RA Fluid Balance (last updated ___ @ 515) Last 8 hours Total cumulative 1145ml IN: Total 1583ml, PO Amt 700ml, IV Amt Infused 883ml OUT: Total 438ml, Urine Amt 438ml Last 24 hours Total cumulative 3646ml IN: Total 4794ml, PO Amt 1060ml, IV Amt Infused 3734ml OUT: Total 1148ml, Urine Amt 1148ml <PHYSICAL EXAM> General: NAD, A&Ox3 CV: RRR, no murmurs RESP: CTAB, normal work of breathing Abd: soft, mildly distended, tympanic, appropriately tender, no rebound or guarding Incisions: port sites clean, dry and intact GU: no spotting on pad, foley draining clear yellow urine Extremities: calves symmetric, non-tender, no edema. pneumoboots on <PERTINENT RESULTS> ___ 05: 40PM GLUCOSE-117* UREA N-15 CREAT-0.7 SODIUM-137 POTASSIUM-4.4 CHLORIDE-100 TOTAL CO2-21* ANION GAP-16 ___ 05: 40PM estGFR-Using this ___ 05: 40PM CALCIUM-7.3* PHOSPHATE-5.2* MAGNESIUM-2.2 ___ 05: 40PM WBC-11.9* RBC-3.71* HGB-11.4 HCT-33.9* MCV-91 MCH-30.7 MCHC-33.6 RDW-14.0 RDWSD-47.2* ___ 05: 40PM PLT COUNT-206 <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. *****'s office with any questions or concerns. Please follow the instructions below. General instructions: * Take your medications as prescribed. * Do not drive while taking narcotics. * Take a stool softener such as colace while taking narcotics to prevent constipation. * Do not combine narcotic and sedative medications or alcohol. * Do not take more than 4000mg acetaminophen (APAP) in 24 hrs. * No strenuous activity until your post-op appointment. * Nothing in the vagina (no tampons, no douching, no sex) for 6 weeks. * No heavy lifting of objects >10 lbs for 6 weeks. * You may eat a regular diet. * You may walk up and down stairs. Incision care: * You may shower and allow soapy water to run over incision; no scrubbing of incision. No tub baths for 6 weeks. * Since you have steri-strips, leave them on. They will fall off on their own or be removed during your followup visit. Call your doctor for: * fever > 100.4F * severe abdominal pain * difficulty urinating * vaginal bleeding requiring >1 pad/hr * abnormal vaginal discharge * redness or drainage from incision * nausea/vomiting where you are unable to keep down fluids/food or your medication Constipation: * Drink ___ liters of water every day. * Incorporate 20 to 35 grams of fiber into your daily diet to maintain normal bowel function. Examples of high fiber foods include: Whole grain breads, Bran cereal, Prune juice, Fresh fruits and vegetables, Dried fruits such as dried apricots and prunes, Legumes, Nuts/seeds. * Take Colace stool softener ___ times daily. * Use Dulcolax suppository daily as needed. * Take Miralax laxative powder daily as needed. * Stop constipation medications if you are having loose stools or diarrhea. To reach medical records to get the records from this hospitalization sent to your doctor at home, call ___.
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On ___, Ms. ___ was admitted to the GYN service after undergoing EXTENSIVE LYSIS OF ADHESIONS;ROBOTIC ASSISTED SUPRACERVICAL HYSTERECTOMY, BILATERAL SALPINGO-OOPHORECTOMY, SACROCERVICOPEXY WITH SYNTHETIC GRAFT AND CYSTOSCOPY. Please see full operative report in ___ for complete details. Immediately post-operatively, her pain was controlled with IV morphine/Toradol and 3 doses of pyridium. A foley catheter was kept in place overnight, and a baseline CBC and chem7 were collected given baseline comorbidities. Her home lasix dose was held. On POD1, she was transitioned to oxycodone/tramadol/acetaminophen with good oral pain control. She underwent a timed voiding trial, and she voided spontaneously. She was tolerating a regular diet, pain was controlled on PO medication, she was passing flatus, she was ambulating independently and voiding urine with minimal discomfort. She was discharged home POD1 with outpatient follow-up scheduled. Discharge Medications: 1. Acetaminophen 650 mg PO Q8H:PRN Pain - Mild RX *acetaminophen 650 mg 1 tablet(s) by mouth every 6 hours as needed Disp #*50 Tablet Refills:*1 2. Docusate Sodium 100 mg PO BID:PRN Constipation - First Line RX *docusate sodium 100 mg 1 capsule(s) by mouth twice per day Disp #*50 Capsule Refills:*0 3. OxyCODONE (Immediate Release) 2.5 mg PO Q4H:PRN pain RX *oxycodone 5 mg 0.5 (One half) tablet(s) by mouth every 4 hours as needed Disp #*12 Tablet Refills:*0 4. TraMADol 25 mg PO Q6H:PRN pain RX *tramadol 50 mg 0.5 (One half) tablet(s) by mouth every 6 hours as needed Disp #*20 Tablet Refills:*0 Discharge Disposition: Home Discharge Diagnosis: UTERINE PROLAPSE Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___
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11087725-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> ___ G4P3 @ ___ presents with an episode of vaginal bleeding that was fairly heavy, soaking 2 pads. She also had clots. She subsequently had leaking fluid, although she has not continued to leak. +AFM. She has not had any bleeding since the episode earlier. She denies abdominal pain or trauma. She did have triage visit a few days ago with contractions but no cervical change. <PAST MEDICAL HISTORY> PNC: -___: ___ 1sst trimester U/S c/s unsure LMP -Labs: B+/Ab-/HBsAg-/RPRNR/RI/HIV-/GBS unknown -Screening: declined serum screening in pregnancy -FFS: WNL, no evidence of previa -GLT: passed -Issues: Recent evaluation of preterm contractions, no e/o preterm labor. OBHx: G4P3 -___ SVD post dates -___ SVD 38 weeks -___ SVD 38 weeks -current GynHx: denies PMH: denies PSH: umbilical hernia with mesh, appy, laser surgery for hernias <SOCIAL HISTORY> ___ <FAMILY HISTORY> non-contributory <PHYSICAL EXAM> On admission: T 97.7, HR 82, BP 109/69, RR 20 Gen: NAD Abd: soft, gravid, NT throughout SSE: Small amount of blood within vault, apparently coming from inside of cervix. Cleared with 3 scopettes. No cervical polyps visualized. No active vaginal bleeding. No pooling fluid, although bloody fluid swabbed to evaluate for ferns (negative ferning on slide). Cervix visually closed SVE: 1cm externally dilated, internally closed, soft, high On discharge: AF VSS Abd: Soft, gravid, nontender GU: pad dry Ext; nontender, no edema <PERTINENT RESULTS> ___ 11: 28PM BLOOD WBC-10.0 RBC-3.51* Hgb-11.0* Hct-32.0* MCV-91 MCH-31.3 MCHC-34.4 RDW-12.6 RDWSD-40.9 Plt ___ ___ 08: 22PM URINE Color-Straw Appear-Clear Sp ___ ___ 08: 22PM URINE Blood-LG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-SM ___ 08: 22PM URINE RBC-2 WBC-2 Bacteri-FEW Yeast-NONE Epi-1 ___ 12: 01AM URINE bnzodzp-NEG barbitr-NEG opiates-NEG cocaine-NEG amphetm-NEG oxycodn-NEG mthdone-NEG ___ 11: 28 pm ANORECTAL/VAGINAL CULTURE Source: Anorectal/Vaginal. **FINAL REPORT ___ R/O GROUP B BETA STREP (Final ___: NEGATIVE FOR GROUP B BETA STREP. ___ 8: 22 pm URINE Source: ___. **FINAL REPORT ___ URINE CULTURE (Final ___: MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION. <MEDICATIONS ON ADMISSION> prenatal vitamins <DISCHARGE MEDICATIONS> 1. Prenatal Vitamins 1 TAB PO DAILY <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> vaginal bleeding in pregnancy, possible placental abruption <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Dear ___, You were admitted to the hospital for bleeding concerning for placental abruption. You were given betamethasone, a steroid which helps the baby's lungs among other benefits. Your bleeding stopped, but we recommended that you remain in the hospital for at least 5 days since the initial episode of bleeding. Our concern is that you will have another episode of bleeding that may put you or your baby at danger or even at risk of death. You are choosing to leave against medical advice and are aware of these risks. Should you experience bleeding again, please contact us immediately at ___. You should avoid strenuous activities. You should not put anything in the vagina, including intercourse. 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. ___ was admitted to the ___ service with vaginal bleeding concerning for placental abruption. She had normal hematocrit and negative urine toxicology. Her bleeding improved. She received antenatal steroids. She had a reactive NST and ___ biophysical profile. It was recommended that she stay in the hospital for at least 5 days after her episode of bleeding, but she chose to leave against medical advice on hospital day #2. Her bleeding had resolved. She was counseled about the risks of leaving against medical advice in the setting of a presumed placental abruption and understood those risks.
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11088013-DS-6
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Phenobarbital / Dilantin / Lamictal / Carafate / Amitriptyline / Soy / Golytely <ATTENDING> ___ <CHIEF COMPLAINT> Menorrhagia, fibroids. <MAJOR SURGICAL OR INVASIVE PROCEDURE> Total laparoscopic hysterectomy, bilateral salpingo-oophorectomy <HISTORY OF PRESENT ILLNESS> Ms. ___ is a ___ G0, premenopausal Caucasian female with known fibroid uterus, epilepsy, SLE and reactive hypoglycemia, glaucoma, gastritis, ulcers, and transaminitis undergoing current evaluation presented to the ___ office requesting definitive surgical treatment for her abnormal bleeding and worsening dysmenorrhea. Pt had underwent a visit to the operating room ___ for a hysteroscopy rollerball endometrial ablation for her menometrorrhagia. Although her symptoms improved for 4 months her menses then resumed the following 2 months and although the abnormal bleeding is not as severe as her pre endometrial ablation state, she was concerned that it may recur. Therefore, she requested definitive surgical treatment with a laparoscopic hysterectomy. She also requested an elective BSO given her age. She understood she would undergo surgical menopause. Informed consent was obtained by ___ her procedure in the office. Of note, the night prior to the surgery, pt presented to the ED with concern for an allergic reaction of unclear etiology. She started her bowel prep of halflytely at approximately 1400. She also took a Carafate suspension at around that time. Of note, the patient has taken golytely in the past with no adverse reaction. She had also recently been switched from Carafate tabs to the suspension secondary to an allergic reaction to the tablets. A few hours after this, the patient had upper lip swelling and flushing. Per the ED, at time of presentation she had a swollen upper lip. She never had any shortness of breath or chest pain. Vital signs on arrival to the ED were 98.7 94 152/92 16 98%/RA. The patient received Benadryl, solumedrol, and famotidine. All of her symptoms resolved. She was observed in the ED for 4 hours and remained stable. Given the late hour, patient admitted to gyn service for obs until surgery in the AM. <PAST MEDICAL HISTORY> CHRONIC NAUSEA/UPPER ABD PAIN HX PUD GI BLEED GALLSTONES SEIZURE DISORDER: Last seizure several years ago ? CHRONIC FATIGUE SYN SYSTEMIC LUPUS ERYTHEMATOSUS: Currently in remission CARPAL TUNNEL SYDROME S/P ARTHROSCOPIC SURGERY HYPOGLYCEMIA: Has been seen at ___ for this <SOCIAL HISTORY> ___ <FAMILY HISTORY> Mother and sister with DM, hypothyroidism, HTN <PHYSICAL EXAM> VS: 97.2 128/82 80 20 96%/RA GEN: NAD, no facial swelling or erythema noted Cardiac: RRR Lungs: CTAB ABD: obese, soft, NT, ND, No R/G Ext: NT <MEDICATIONS ON ADMISSION> ERYTHROMYCIN ETHYLSUCCINATE - 200 mg/5 mL Suspension for Reconstitution - 1.5 cc(s) by mouth three times a day FEXOFENADINE - 180 mg Tablet - 1 Tablet(s) by mouth daily HYDROCORTISONE ACETATE [ANUSOL-HC] - (Not Taking as Prescribed: when needed) - 25 mg Suppository - appy rectally twice a day HYDROXYCHLOROQUINE - 200 mg Tablet - 1 Tablet(s) by mouth once a day LEVETIRACETAM [KEPPRA] - 500 mg Tablet - 1 Tablet(s) by mouth twice a day BRAND NAME MEDICALLY NECESSARY. NO SUBSTITUTION. - No Substitution PANTOPRAZOLE - 40 mg Tablet, Delayed Release (E.C.) - 1 Tablet(s) by mouth twice a day SUCRALFATE [CARAFATE] - (Prescribed by Other Provider) - Dosage uncertain Medications - OTC ACETAMINOPHEN [ACETAMINOPHEN EXTRA STRENGTH] - (Prescribed by Other Provider) - 500 mg Tablet - ___ Tablet(s) by mouth every 6 hours as needed for pain. DOCUSATE SODIUM - (Prescribed by Other Provider) - 100 mg Capsule - 1 Capsule(s) by mouth twice a day ERGOCALCIFEROL (VITAMIN D2) [VITAMIN D] - (Prescribed by Other Provider) - 1,000 unit Capsule - 1 Capsule(s) by mouth once daily MULTIVITAMIN - (Prescribed by Other Provider: 1 tab by mouth once daily) - Dosage uncertain <DISCHARGE MEDICATIONS> 1. Oxycodone-Acetaminophen ___ mg Tablet Sig: ___ Tablets PO Q4H (every 4 hours) as needed for Pain. Disp: *20 Tablet(s)* Refills: *0* 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp: *60 Capsule(s)* Refills: *2* -Instruction for pt to resume all her regular home medication. <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> Menorrhagia, fibroids. <DISCHARGE CONDITION> Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> General instructions: * Take your medications as prescribed. * Do not drive while taking narcotics. * No strenuous activity, nothing in the vagina (no tampons, no douching, no sex), no heavy lifting of objects >10 lbs for 12 weeks. * You may eat a regular diet.
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Pt was taken to the OR in the morning for her scheduled total laparoscopic hysterectomy and bilateral salpingo-oopherectomy. Pt was found to have a fibroid uterus, filmy adhesions of rectosigmoid to sidewall, but the surgery was otherwise uneventful. Please see the operative note by ___ complete details. Pt's recovery course was complicated by the following event: on the night of the surgery, pt complained of lip swelling and itchiness on her neck and chest, sensation was similar to what brought her to the ED on ___. ___ medical record was reviewed and no new medication was given at that time. Pt was examined thoroughly, and no other swelling, dysarthria, or SOB was appreciated. All her vital signs and the physical exam were benign. Pt was monitored closely and provided Benadryl PO for symptomatic relief. The lip swelling and itchiness resolved on post operative day#1. Pt's regular home medications were restarted without any issue. Pt was discharged on the evening of post-operative day #1 in stable condition: afebrile, able to eat regular food, under adequate pain control with oral medications, and ambulating and urinating without difficulty.
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| 245
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11089965-DS-7
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Sulfa (Sulfonamides) / Latex <ATTENDING> ___ <CHIEF COMPLAINT> Fever, abdominal pain, nausea, diarrhea <MAJOR SURGICAL OR INVASIVE PROCEDURE> none <HISTORY OF PRESENT ILLNESS> 41 G3P2 status post spontaneous vaginal delivery ___ presents to ED w/ accute onset abd pain, nausea and diarrhea approx 24hr prior to this admission. She also passed two large clots within 12 hrs of admission. She states that her family has had a stomach bug over the weekend with non-bloody diarrhea. Her nausea has limited her oral intake. She describes a suprapubic pain with radiation to the left lower quadrant. Patient required dilaudid in ED to control pain. <PAST MEDICAL HISTORY> OB history: G3P2 - Vaginal delivery x 2, intrauterine fetal demise x 1 GYN HX: Normal pap smears, fibroid uterus PMH: Carpal Tunnel syndrome PSH: None <SOCIAL HISTORY> ___ <FAMILY HISTORY> Non-contributory <PHYSICAL EXAM> T 100.4 Uncomfortable HEENT normal Lungs clear regular, rate, rhythm Abdomen non-distended, bowel signs present, tympanic. Fundal tenderness, LLQ tenderness with mild rebound. <PERTINENT RESULTS> ___ 08: 00PM BLOOD WBC-11.0 RBC-4.31 Hgb-14.3 Hct-41.0 MCV-95 MCH-33.1* MCHC-34.8 RDW-13.5 Plt ___ ___ 08: 00PM BLOOD Neuts-82.8* Lymphs-12.2* Monos-4.3 Eos-0.2 Baso-0.4 ___ 08: 00PM BLOOD Plt ___ ___ 08: 00PM BLOOD ___ PTT-27.2 ___ ___ 08: 00PM BLOOD Glucose-93 UreaN-10 Creat-0.8 Na-141 K-3.7 Cl-103 HCO3-30 AnGap-12 ___ 08: 00PM BLOOD ALT-35 AST-29 AlkPhos-81 TotBili-0.6 ___ 08: 00PM BLOOD Lipase-36 ___ 08: 36PM BLOOD Lactate-2.1* ___ 08: 36PM LACTATE-2.1* ___ 12: 28AM URINE ___ BACTERIA-MOD YEAST-NONE ___ 12: 28AM URINE BLOOD-LG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-SM ___ 12: 28AM URINE COLOR-Straw APPEAR-Clear SP ___ Transvaginal ultrasound No evidence of retained products of conception CT Abdomen Limited study in the abscence of IV contrast. No evidence of collitis. <MEDICATIONS ON ADMISSION> None <DISCHARGE MEDICATIONS> None <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> endometritis viral gastritis <DISCHARGE CONDITION> good <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> routine postpartum instructions call for fever or worsening abdominal pain
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Patient was admitted to postpartum given abdominal tenderness, low grade fever and dehydration. She was started on Ampicillin, Gentamycin and Clindamycin for presumed endometritis. Urine culture was intially suspicious for UTI. She was initially treated with dilaudid for pain management. . She remained afebrile for the duration of her admission. Stool culture, ova and parasites was negative. Urine culture eventually showed mixed species consistent with contamination. Abdominal tenderness improved on hospital day 2 and diarrhea resolved upon admission. . She was evenutally discharged on hospital day 3 afebrile after 2 days of ampicillin, gentamycin and clindamycin. Abdominal tenderness, diarrhea and nausea were resolved. She was tolerating regular diet and not requiring any pain medication.
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| 176
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11090590-DS-17
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> ?LOF <MAJOR SURGICAL OR INVASIVE PROCEDURE> vaginal delivery <HISTORY OF PRESENT ILLNESS> ___ ___ at 34w6d presents with leakage of clear fluid around 0700. Noted small amount of fluid when she was waking up from sleeping. Now not leaking. Denies VB, and reports AFM. Ctxs q5mins. <PAST MEDICAL HISTORY> PNC: ___: ___ by LMP - B+/Ab neg/Rub I/Var I/RPR nr/HBsAg n/HIV n/GBS unknown - LR NIPT - FFS wnl - GLT wnl - currently treating for flu PMH: h/o HSV, no active lesions during pregnancy - obesity - migraine headaches - depression ObHx G1: FT, vaginal delivery, ___ G2-8: SAB/TAB with multiple D&Cs GYN hx: - as above PSH: - D&C x 4 - ___ liposuction with VBL - ___ Excision of ganglion cyst of the left dorsum of the foot - ___ Derotational fifth digit arthroplasties bilateral - bilateral corn removal <SOCIAL HISTORY> ___ <FAMILY HISTORY> noncontributory <PHYSICAL EXAM> ___ 11: 26Temp.: 99.0°F ___ 11: 26Resp.: 20 / min ___ 11: 26BP: 123/81 (90) ___ ___: 97 Gen: NAD Resp: breathing comfortably Abd: soft, NT, gravid SSE: neg pooling, positive nitrazine, neg ferning, positive amnisure -> repeat SSE after ~1hr neg pooling, neg nitrazine, neg ferning SVE: 2/long/high (1130) -> ___ (1330) -> ___ (1725) TAUS: cephalic, MVP 5cm <MEDICATIONS ON ADMISSION> PNV, acetaminophen <DISCHARGE MEDICATIONS> 1. Acetaminophen ___ mg PO Q6H: PRN Pain - Mild RX *acetaminophen 500 mg 1 - 2 tablet(s) by mouth q 6 hrs Disp #*30 Tablet Refills: *0 2. Docusate Sodium 100 mg PO BID: PRN Constipation RX *docusate sodium 100 mg 1 tablet(s) by mouth daily Disp #*10 Tablet Refills: *0 3. Ibuprofen 600 mg PO Q6H: PRN Moderate Pain RX *ibuprofen 600 mg 1 tablet(s) by mouth q 6 hrs Disp #*30 Tablet Refills: *0 <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> vaginal delivery preterm delivery <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
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Ms. ___ was admitted to the antepartum after concern for rupture of membranes on ___. She began a course of betamethasone and was transferred to the antepartum floor from labor and delivery, however within a few hours of arrival she became more uncomfortable and returned to labor and delivery where her labor progressed and she underwent uncomplicated spontaneous vaginal delivery. Her postpartum course was uncomplicated and she was discharged home in stable condition on postpartum day 2.
| 684
| 100
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11091673-DS-9
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> codeine / NSAIDS (Non-Steroidal Anti-Inflammatory Drug) / Tegaderm <ATTENDING> ___ ___ Complaint: Ovarian Cancer <MAJOR SURGICAL OR INVASIVE PROCEDURE> Exploratory laparotomy, interval tumor debulking surgery, bilateral salpingo-oophorectomy, omentectomy, enterolysis. <HISTORY OF PRESENT ILLNESS> ___ G0 with high grade serous ovarian cancer presents for follow up. Oncologic History: - ___: A/P CT demonstrated a 13.6-cm mixed solid and cystic mass centered within the left hemipelvis, involving the left hemipelvic side wall and abutting the sigmoid colon, with moderate left hydroureteronephrosis. Findings were suspicious for adnexal malignancy. Retroperitoneal lymphadenopathy and diffuse peritoneal metastases were also noted. CA-125 was 310 at the time of diagnosis. - ___: biopsy of a mass that extended into the apex of the vagina. Pathology demonstrated a high-grade squamous intraepithelial lesion which was positive for P16. - ___: peritoneal biopsy demonstrated a high-grade serous carcinoma which stained positive for P53, P16, WT1 and PAX8; negative for P63. - ___: C1D1 with carboplatin/doxil (taxol deferred given history of neuropathy) - ___: negative LENIs, PCN placed - ___: stent placed - urostomy tube remains - ___: urostomy tube removed - reaction to Tegaderm - ___: CT torso: interval improvement in disease, improvement in left hydrouteronephrosis - ___: C4D1 Patient reports receiving her fourth cycle of chemotherapy two days ago. She has been tolerating her treatments well. She denies weight loss or changes. She feels that the vaginal mass an abdominal fullness has improved since initiating chemotherapy. Since her last chemo treatment she reports noticing swelling in her right lower extremity. She feels that it is not increased from prior. She denies pain in her legs. With regards to her nephrostomy, she has felt better since it was removed. She has the stent in place and has been tolerating it well. She had an episode of dysuria 2 weeks ago but reports her urine culture was negative. She denies hematuria. She reports being diagnosed with a fungal infection on her back and under her breast. She has been using topical antifungal creams with good relief. 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> OBHx: G0 GYNHx: - menopause in her late ___ - hx Premarin use ___ yrs - denies hx abnl Paps - denies hx pelvic infections PMHx: - HLD - arthritis - heart murmur - neuropathy - denies DM, HTN, significant cardiac or pulmonary disease PSHx: - mmy x2 (age ___ and ___) - TAH (age ___ - appy (during one of aforementioned GYN surgeries) - breast bx for benign findings in the past (uncertain date) - bilateral knee arthroscopy - cataract surgery <SOCIAL HISTORY> ___ <FAMILY HISTORY> - maternal grandmother deceased of uterine v. ovarian CA - mother underwent a hysterectomy at age ___ - maternal cousin with breast CA and maternal aunt with unknown malignancy <PHYSICAL EXAM> General: NAD, comfortable CV: RRR Lungs: CTAB Abdomen: soft, non-distended, appropriately tender to palpation without rebound or guarding, incision/dressing clean/dry/intact Extremities: no edema, no TTP, pneumoboots in place bilaterally <PERTINENT RESULTS> ___ 12: 57PM BLOOD WBC-3.8* RBC-2.73* Hgb-8.8* Hct-27.5* MCV-101* MCH-32.2* MCHC-32.0 RDW-19.1* RDWSD-70.4* Plt ___ ___ 07: 25AM BLOOD WBC-7.3 RBC-2.48* Hgb-8.0* Hct-25.3* MCV-102* MCH-32.3* MCHC-31.6* RDW-19.3* RDWSD-72.4* Plt ___ ___ 06: 00AM BLOOD WBC-7.3 RBC-2.49* Hgb-7.9* Hct-25.4* MCV-102* MCH-31.7 MCHC-31.1* RDW-19.6* RDWSD-72.7* Plt ___ ___ 06: 00AM BLOOD Neuts-77.6* Lymphs-12.8* Monos-8.7 Eos-0.3* Baso-0.1 Im ___ AbsNeut-5.69 AbsLymp-0.94* AbsMono-0.64 AbsEos-0.02* AbsBaso-0.01 ___ 05: 55AM BLOOD WBC-5.2 RBC-2.45* Hgb-7.9* Hct-24.9* MCV-102* MCH-32.2* MCHC-31.7* RDW-18.8* RDWSD-70.5* Plt ___ ___ 05: 55AM BLOOD Neuts-73.3* Lymphs-16.6* Monos-8.7 Eos-0.4* Baso-0.2 Im ___ AbsNeut-3.80 AbsLymp-0.86* AbsMono-0.45 AbsEos-0.02* AbsBaso-0.01 ___ 02: 30AM BLOOD WBC-4.0 RBC-2.47* Hgb-8.0* Hct-24.7* MCV-100* MCH-32.4* MCHC-32.4 RDW-18.6* RDWSD-68.3* Plt ___ ___ 02: 30AM BLOOD Neuts-65.8 ___ Monos-11.8 Eos-0.8* Baso-0.3 Im ___ AbsNeut-2.62 AbsLymp-0.77* AbsMono-0.47 AbsEos-0.03* AbsBaso-0.01 ___ 05: 44AM BLOOD WBC-3.6* RBC-2.41* Hgb-7.9* Hct-24.0* MCV-100* MCH-32.8* MCHC-32.9 RDW-18.6* RDWSD-68.3* Plt ___ ___ 07: 18AM BLOOD WBC-3.6* RBC-2.81* Hgb-9.0* Hct-28.0* MCV-100* MCH-32.0 MCHC-32.1 RDW-18.5* RDWSD-68.3* Plt ___ ___ 06: 44AM BLOOD WBC-3.9* RBC-2.58* Hgb-8.3* Hct-26.0* MCV-101* MCH-32.2* MCHC-31.9* RDW-18.7* RDWSD-69.1* Plt ___ ___ 06: 58AM BLOOD WBC-4.7 RBC-2.77* Hgb-9.0* Hct-28.7* MCV-104* MCH-32.5* MCHC-31.4* RDW-19.1* RDWSD-72.8* Plt ___ ___ 12: 57PM BLOOD Glucose-150* UreaN-13 Creat-0.7 Na-140 K-3.9 Cl-105 HCO3-24 AnGap-11 ___ 12: 57PM BLOOD Calcium-8.4 Phos-3.6 Mg-1.7 ___ 07: 25AM BLOOD Glucose-133* UreaN-13 Creat-0.7 Na-136 K-4.9 Cl-100 HCO3-25 AnGap-11 ___ 07: 25AM BLOOD Calcium-8.6 Phos-3.9 Mg-2.6 ___ 06: 00AM BLOOD Glucose-99 UreaN-15 Creat-0.8 Na-135 K-4.6 Cl-98 HCO3-23 AnGap-14 ___ 06: 00AM BLOOD Calcium-8.8 Phos-2.7 Mg-2.0 ___ 05: 55AM BLOOD Glucose-96 UreaN-9 Creat-0.6 Na-136 K-4.3 Cl-98 HCO3-25 AnGap-13 ___ 05: 55AM BLOOD Calcium-8.8 Phos-2.7 Mg-1.8 ___ 02: 30AM BLOOD Glucose-88 UreaN-7 Creat-0.6 Na-138 K-3.5 Cl-97 HCO3-22 AnGap-19* ___ 02: 30AM BLOOD Calcium-8.7 Phos-2.7 Mg-1.8 ___ 07: 18AM BLOOD Glucose-108* UreaN-7 Creat-0.6 Na-141 K-4.0 Cl-101 HCO3-28 AnGap-12 ___ 05: 44AM BLOOD Calcium-8.6 Phos-2.7 Mg-1.8 ___ 12: 48AM BLOOD Glucose-118* UreaN-11 Creat-0.7 Na-143 K-3.6 Cl-105 HCO3-26 AnGap-12 ___ 12: 48AM BLOOD Calcium-8.8 Phos-2.2* Mg-1.8 ___ 06: 44AM BLOOD Glucose-117* UreaN-9 Creat-0.7 Na-143 K-4.2 Cl-105 HCO3-27 AnGap-11 ___ 06: 44AM BLOOD Calcium-8.8 Phos-2.6* Mg-1.8 ___ 06: 58AM BLOOD Glucose-111* UreaN-7 Creat-0.7 Na-142 K-3.9 Cl-105 HCO3-26 AnGap-11 ___ 06: 58AM BLOOD Calcium-9.1 Phos-3.2 Mg-1.8 ___ 02: 30AM BLOOD CK-MB-5 cTropnT-0.08* ___ 02: 30AM BLOOD CK(CPK)-114 ___ 08: 51AM BLOOD CK-MB-4 cTropnT-0.06* ___ 12: 48AM BLOOD CK-MB-4 cTropnT-0.10* ___ 06: 44AM BLOOD CK-MB-4 cTropnT-0.09* ___ 06: 44AM BLOOD CK(CPK)-133 <MEDICATIONS ON ADMISSION> Active Medication list as of ___: Medications - Prescription DEXAMETHASONE - dexamethasone 4 mg tablet. 1 tablet(s) by mouth twice a day Take 1 tab BID for 2 days following chemo ECONAZOLE - econazole 1 % topical cream. 1 application to fungal infection around nephrostomy tube once a day - (Prescribed by Other Provider) ONDANSETRON HCL - ondansetron HCl 8 mg tablet. 1 tablet(s) by mouth as directed Take 1 BID for 2 days after chemo; Q8H prn nausea PROCHLORPERAZINE MALEATE - prochlorperazine maleate 10 mg tablet. 1 tablet(s) by mouth every six (6) hours as needed for nausea TEMAZEPAM - temazepam 15 mg capsule. 1 capsule(s) by mouth at hs prn insomnia - (Prescribed by Other Provider) Medications - OTC ACETAMINOPHEN [TYLENOL] - Dosage uncertain - (Prescribed by Other Provider; as needed) RED YEAST RICE - red yeast rice 600 mg tablet. 1 tablet(s) by mouth twice a day last dose pre-op ___ - (Prescribed by Other Provider) <DISCHARGE MEDICATIONS> 1. Acetaminophen ___ mg PO Q6H: PRN Pain - Mild RX *acetaminophen 500 mg 1 tablet(s) by mouth q6h PRN Disp #*50 Tablet Refills: *1 2. Aspirin 81 mg PO DAILY RX *aspirin 81 mg 1 tablet(s) by mouth daily Disp #*100 Tablet Refills: *1 3. Atorvastatin 80 mg PO QPM RX *atorvastatin 80 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills: *11 4. Docusate Sodium 100 mg PO BID RX *docusate sodium 100 mg 1 capsule(s) by mouth once a day Disp #*50 Capsule Refills: *1 5. Enoxaparin Sodium 40 mg SC QHS RX *enoxaparin 40 mg/0.4 mL 40 mg SC daily Disp #*25 Syringe Refills: *0 6. Metoprolol Succinate XL 100 mg PO DAILY RX *metoprolol succinate 100 mg 1 tablet(s) by mouth once a day Disp #*50 Tablet Refills: *1 7. Senna 8.6 mg PO BID: PRN Constipation - First Line RX *sennosides [senna] 8.6 mg 1 tablet by mouth daily Disp #*30 Tablet Refills: *1 8. Triamcinolone Acetonide 0.1% Cream 1 Appl TP TID: PRN rash <DISCHARGE DISPOSITION> Home With Service Facility: ___ <DISCHARGE DIAGNOSIS> Advanced ovarian cancer status post neoadjuvant chemotherapy. No ST-segment elevation myocardial ischemia due to demand <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Dear ___ ___ were admitted to the gynecologic oncology service after undergoing the procedures listed below. ___ have recovered well after your operation, and the team feels that ___ are safe to be discharged home. Please follow these instructions: Abdominal instructions: * Your staples will be removed within 2 weeks from your surgery. This appointment should already been scheduled for ___. Please call if ___ do not have an appointment scheduled. * Take your medications as prescribed. We recommend ___ take non-narcotics (i.e. Tylenol, ibuprofen) regularly for the first few days post-operatively, and use the narcotic as needed. As ___ start to feel better and need less medication, ___ should decrease/stop the narcotic first. * Take a stool softener to prevent constipation. ___ were prescribed Colace. If ___ continue to feel constipated and have not had a bowel movement within 48hrs of leaving the hospital ___ can take a gentle laxative such as milk of magnesium. * Do not drive while taking narcotics. * Do not combine narcotic and sedative medications or alcohol. * Do not take more than 4000mg acetaminophen (tylenol) in 24 hrs. * No strenuous activity until your post-op appointment. * Nothing in the vagina (no tampons, no douching, no sex) for 12 weeks. * No heavy lifting of objects >10 lbs for 6 weeks. * ___ may eat a regular diet. * It is safe to walk up stairs. Incision care: * ___ may shower and allow soapy water to run over incision; no scrubbing of incision. No bath tubs for 6 weeks. * ___ should remove your port site dressings ___ days after your surgery, if they have not already been removed in the hospital. Leave your steri-strips on. If they are still on after ___ days from surgery, ___ may remove them. * If ___ have staples, they will be removed at your follow-up visit. Constipation: * Drink ___ liters of water every day. * Incorporate 20 to 35 grams of fiber into your daily diet to maintain normal bowel function. Examples of high fiber foods include: Whole grain breads, Bran cereal, Prune juice, Fresh fruits and vegetables, Dried fruits such as dried apricots and prunes, Legumes, Nuts/seeds. * Take Colace stool softener ___ times daily. * Use Dulcolax suppository daily as needed. * Take Miralax laxative powder daily as needed. * Stop constipation medications if ___ are having loose stools or diarrhea. To reach medical records to get the records from this hospitalization sent to your doctor at home, call ___. *** Lovenox injections: * Patients having surgery for cancer have risk of developing blood clots after surgery. This risk is highest in the first four weeks after surgery. ___ will be discharged with a daily Lovenox (blood thinning) medication. This is a preventive dose of medication to decrease your risk of a forming a blood clot. A visiting nurse ___ assist ___ in administering these injections.
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Ms. ___ was admitted to the gynecologic oncology service after undergoing exploratory laparotomy, BSO, extensive LOA and interval tumor debulking for high grade serous ovarian carcinoma. Please see the operative report for full details. Her post-operative course is detailed as follows. Immediately postoperatively, her pain was controlled with an epidural. She had significant post operative nausea with slow return to bowel function. Nausea was controlled with IV Reglan and IV Zofran PRN. Her diet was advanced slowly. Urine output was borderline initially post operatively, averaging around 20 cc's/hr on post operative day 2. She was continued on IVF at 125 cc/hr while her diet was advanced slowly due to the nausea. Urine output improved on post operative day 3. By post operative day 4, the patient was passing flatus and the patient's nausea had improved. She was tolerating PO intake and PO pain medications, at which point the epidural and foley catheter were removed. On post-operative day 2, the patient had intermittent desaturations into the mid ___. Her exam was stable and she was encouraged to use her incentive spirometer. She was placed on O2, which was weaned as tolerated by post operative day 3. A chest x-ray, EKG, CTA chest and TTE were obtained to assess her desaturations. She was also placed on telemetry and continuous O2 monitoring. CXR on ___ showed small bilateral pleural effusions with bibasilar atelectasis, concerning for CHF. CTA chest on ___ showed no evidence of PE or aortic abnormality with moderate right and trace left pleural effusions with adjacent atelectasis. EKG on ___ showed normal sinus rhythm. TTE on ___ showed an EF of 80% with severe mitral regurgitation. On telemetry on ___ the patient was noted to have brief SVTs that spontaneously resolved. A repeat EKG was obtained at that time which showed normal sinus rhythm with T wave inversions in V2-V3. Troponins were 0.08 at that time on ___ at 0230. She was completely asymptomatic at the time of the event. Repeat troponins on ___ at 0900 were 0.06. Cardiology was consulted and recommended starting the patient on metoprolol 6.25mg q6h, atorvastatin 20mg qd and aspirin 81mg qd. Patient was noted to have SVTs on telemetry again on ___ that spontaneously resolved. Repeat EKG at that time showed normal sinus rhythm with T wave inversion in V2-V3. At that time troponins were 0.10 and CK-MB was 4. Per cardiology, metoprolol tartrate was increased to 12.5mg Q6H on ___ and again to 25mg Q6H on ___. Cardiology recommended a stress test, which they agreed could be performed outpatient. They recommended that the patient be discharged on metoprolol succinate 100mg qd, atorvastatin 80mg qd and aspirin 81mg qd. By post-operative day 7, 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 with gynecology oncology and cardiology.
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11092703-DS-12
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Amoxicillin <ATTENDING> ___. <CHIEF COMPLAINT> abdominal pain <MAJOR SURGICAL OR INVASIVE PROCEDURE> Dilation and curettage <HISTORY OF PRESENT ILLNESS> ___ yo ___ s/p 10 wk D&C TAB presented to ED with abdominal pain same day she left the hospital earlier in the afternoon. No CP/dizziness, palpitations, bleeding (just spotting), or other symptoms. <PAST MEDICAL HISTORY> PAST GYN HX: - Cycles are fairly irregular (q15-30 days) last ___ days, qmonthly - Has not had PAP smear before - No hx of STI - Sexually active with 1 partner PAST MEDICAL HX: * benign PAST SURGICAL HX: * Breast reduction * D&C today <SOCIAL HISTORY> ___ <FAMILY HISTORY> non-contributory <PHYSICAL EXAM> Exam on Admission: General: NAD, pale Chest: RRR, lung CTAB Abdomen: Soft, NT, ND Pelvic exam deferred Exam on Discharge: General: NAD Chest: RRR, no m/r/g Lungs: CTAB Abdomen: soft, NT, ND Gyn: minimal spotting <PERTINENT RESULTS> ___ 01: 40PM BLOOD WBC-8.7 RBC-2.31* Hgb-7.2* Hct-20.9* MCV-90 MCH-31.2 MCHC-34.5 RDW-12.5 Plt ___ ___ 05: 30AM BLOOD WBC-12.6* RBC-2.33* Hgb-7.2* Hct-20.8* MCV-89 MCH-31.1 MCHC-34.8 RDW-13.3 Plt ___ ___ 12: 45AM BLOOD WBC-14.0* RBC-2.62* Hgb-8.2* Hct-24.2* MCV-93 MCH-31.4 MCHC-34.0 RDW-12.4 Plt ___ ___ 10: 30PM BLOOD WBC-10.9 RBC-2.55*# Hgb-8.0*# Hct-23.2*# MCV-91 MCH-31.2 MCHC-34.4 RDW-12.1 Plt ___ ___ 07: 20PM BLOOD WBC-17.9* RBC-3.75* Hgb-11.8* Hct-34.0* MCV-91 MCH-31.4 MCHC-34.6 RDW-12.3 Plt ___ ___ 10: 30PM BLOOD Neuts-91.7* Lymphs-6.5* Monos-1.7* Eos-0.1 Baso-0 ___ 07: 20PM BLOOD Neuts-94.3* Lymphs-5.0* Monos-0.5* Eos-0.1 Baso-0.2 ___ 01: 40PM BLOOD Plt ___ ___ 05: 30AM BLOOD Plt ___ ___ 12: 45AM BLOOD Plt ___ ___ 12: 45AM BLOOD ___ PTT-30.9 ___ ___ 10: 30PM BLOOD Plt ___ ___ 07: 20PM BLOOD Plt ___ ___ 07: 20PM BLOOD ___ PTT-31.3 ___ ___ 12: 45AM BLOOD ___ 07: 20PM BLOOD Glucose-140* UreaN-6 Creat-0.6 Na-135 K-3.5 Cl-101 HCO3-21* AnGap-17 ___ 07: 20PM BLOOD Calcium-9.8 Phos-1.5* Mg-1.8 ___ 10: 33PM BLOOD Lactate-0.4* ___ 07: 28PM BLOOD Lactate-3.4* ___ 10: 33PM BLOOD Hgb-8.0* calcHCT-24 <MEDICATIONS ON ADMISSION> None <DISCHARGE MEDICATIONS> 1. methylergonovine 0.2 mg Tablet Sig: One (1) Tablet PO x1 for 1 doses: take at 10pm on ___. Disp: *1 Tablet(s)* Refills: *0* 2. ferrous gluconate 325 mg (36 mg iron) Tablet Sig: One (1) Tablet PO twice a day. 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: *30 Tablet(s)* Refills: *2* 4. oxycodone-acetaminophen ___ mg Tablet Sig: ___ Tablets PO Q6H (every 6 hours) as needed for pain. Disp: *20 Tablet(s)* Refills: *0* <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> Hematometra and blood loss anemia <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> General instructions: * Take your medications as prescribed. * Do not drive while taking narcotics. * Do not combine narcotic and sedative medications or alcohol * Do not take more than 4000mg acetaminophen (APAP) in 24 hrs * Nothing in the vagina (no tampons, no douching, no sex2 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 ___. 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
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Ms. ___ is a ___ G1P0 who presented to the ED the evening after her TAB with abdominal pain and anemia. She was found to have hematometra and underwent dilation and curettage. Please see operative report for full details. She received methergine 0.2 mg PO q8 and bleeding was controlled. Her hematocrit dropped from 34.0 to a low of 20.8. She remained asymptomatic, however, with no episodes of dizziness, syncope, chest pain, or shortness of breath. HR 95-100 and BP ___. She declined transfusion, but was written for iron supplementation and continued for 24 hours of methergine. She was able to tolerate a regular diet, ambulate, void on her own, and pain was well-controlled on PO medications before being discharged in good condition on post-operative days ___.
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11093781-DS-11
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> NSAIDS (Non-Steroidal Anti-Inflammatory Drug) / azithromycin <ATTENDING> ___. <CHIEF COMPLAINT> suspected placenta accreta <MAJOR SURGICAL OR INVASIVE PROCEDURE> Diagnostic cystoscopy, bilateral ureteral stent placement, exploratory laparotomy, transfundal cesarean delivery, total hysterectomy, oversew of deserosalized bladder, bilateral salpingectomy <HISTORY OF PRESENT ILLNESS> ___ G2P1 presents for scheduled cesarean hysterectomy for suspected placenta accreta <PAST MEDICAL HISTORY> ___: ___ ___: Boy, ___, LTCS, IOL for oligohydramnios, prolonged labor, FTP. Complicated by GDM A1 and postpartum PEC. GYNHx: Cervical dysplasia HPV + ___, PMHx: HTN ADHD Obesity BMI 47 Asthma PSHx: Hx of RNY gastric bypass, ___, ___, lost 100 lbs. LTCS Back surgery s/p car trauma, fusion of sacrum into pelvis Rod in right leg and screws in knee, had 9u blood transfusion ___ after MVA Fasciotomy right leg from trauma <SOCIAL HISTORY> ___ <FAMILY HISTORY> No known history of Down syndrome, chromosomal abnormalities, or birth defects. <PHYSICAL EXAM> VS: Afebrile, Vital signs stable Neuro/Psych: no acute distress, Oriented x3, Affect Normal Heart: regular rate and rhythm Lungs: clear to auscultation bilaterally Abdomen: soft, appropriately tender, incision clean/dry/intact Pelvis: minimal bleeding Extremities: warm and well perfused, no calf tenderness, no edema <PERTINENT RESULTS> ___ 11: 39PM BLOOD WBC-8.3 RBC-3.22* Hgb-9.2* Hct-28.1* MCV-87 MCH-28.6 MCHC-32.7 RDW-13.8 RDWSD-43.7 Plt ___ ___ 01: 41AM BLOOD WBC-9.0 RBC-3.46* Hgb-10.1* Hct-30.3* MCV-88 MCH-29.2 MCHC-33.3 RDW-13.9 RDWSD-44.2 Plt ___ ___ 04: 03AM BLOOD WBC-11.6* RBC-3.73* Hgb-10.8* Hct-32.1* MCV-86 MCH-29.0 MCHC-33.6 RDW-13.8 RDWSD-42.7 Plt ___ ___ 11: 03PM BLOOD WBC-14.3* RBC-3.81* Hgb-11.0* Hct-33.0* MCV-87 MCH-28.9 MCHC-33.3 RDW-13.7 RDWSD-42.5 Plt ___ ___ 04: 34PM BLOOD WBC-14.6* RBC-3.95 Hgb-11.5 Hct-34.9 MCV-88 MCH-29.1 MCHC-33.0 RDW-13.5 RDWSD-43.8 Plt ___ ___ 01: 52PM BLOOD WBC-14.3* RBC-3.94 Hgb-11.4 Hct-34.5 MCV-88 MCH-28.9 MCHC-33.0 RDW-13.4 RDWSD-42.6 Plt ___ ___ 01: 41AM BLOOD Neuts-80.8* Lymphs-9.0* Monos-8.9 Eos-0.3* Baso-0.2 Im ___ AbsNeut-7.24* AbsLymp-0.81* AbsMono-0.80 AbsEos-0.03* AbsBaso-0.02 ___ 01: 52PM BLOOD Neuts-78.0* Lymphs-13.7* Monos-6.6 Eos-0.8* Baso-0.3 Im ___ AbsNeut-11.17* AbsLymp-1.97 AbsMono-0.95* AbsEos-0.12 AbsBaso-0.05 ___ 04: 03AM BLOOD ___ PTT-25.2 ___ ___ 11: 03PM BLOOD ___ PTT-25.4 ___ ___ 02: 45PM BLOOD ___ PTT-20.4* ___ ___ 11: 30AM BLOOD ___ PTT-23.8* ___ ___ 10: 16AM BLOOD ___ PTT-24.8* ___ ___ 04: 03AM BLOOD ___ 11: 03PM BLOOD ___ 02: 45PM BLOOD ___ 11: 30AM BLOOD ___ 10: 16AM BLOOD ___ 04: 03AM BLOOD Glucose-92 UreaN-12 Creat-0.5 Na-138 K-4.7 Cl-107 HCO3-19* AnGap-12 ___ 11: 03PM BLOOD Glucose-91 UreaN-12 Creat-0.5 Na-137 K-4.5 Cl-105 HCO3-21* AnGap-11 ___ 01: 52PM BLOOD Glucose-79 UreaN-11 Creat-0.4 Na-137 K-4.5 Cl-105 HCO3-20* AnGap-12 ___ 04: 03AM BLOOD ALT-13 AST-20 ___ 11: 03PM BLOOD ALT-13 AST-19 ___ 04: 03AM BLOOD Calcium-8.1* Phos-4.2 Mg-1.7 ___ 11: 03PM BLOOD Calcium-7.9* Phos-4.0 Mg-1.6 ___: 52PM BLOOD Calcium-8.0* Phos-3.6 Mg-1.7 ___ 02: 59PM BLOOD Type-ART pH-7.32* ___ 11: 46AM BLOOD Type-ART pO2-190* pCO2-42 pH-7.31* calTCO2-22 Base XS--4 Intubat-INTUBATED ___ 10: 58AM BLOOD Type-ART pO2-250* pCO2-40 pH-7.35 calTCO2-23 Base XS--3 Intubat-INTUBATED ___ 10: 32AM BLOOD Type-ART FiO2-50 pO2-211* pCO2-30* pH-7.46* calTCO2-22 Base XS-0 Intubat-NOT INTUBA Vent-SPONTANEOU ___ 02: 59PM BLOOD Lactate-1.4 ___ 11: 46AM BLOOD Glucose-77 Lactate-2.3* Na-137 K-5.0 Cl-106 ___ 10: 58AM BLOOD Glucose-82 Lactate-1.7 Na-132* K-4.5 Cl-105 ___ 10: 32AM BLOOD Glucose-71 Lactate-1.4 Na-133 K-3.6 Cl-106 ___ 02: 08PM BLOOD Hgb-11.8* calcHCT-35 ___ 11: 46AM BLOOD Hgb-10.5* calcHCT-32 ___ 10: 58AM BLOOD Hgb-9.5* calcHCT-29 ___ 10: 32AM BLOOD Hgb-6.9* calcHCT-21 ___ 02: 59PM BLOOD freeCa-1.06* ___ 11: 46AM BLOOD freeCa-1.05* ___ 10: 58AM BLOOD freeCa-1.09* ___ 10: 32AM BLOOD freeCa-0.97* <MEDICATIONS ON ADMISSION> The Preadmission Medication list may be inaccurate and requires futher investigation. 1. Labetalol 200 mg PO BID 2. Multivitamins 1 TAB PO DAILY 3. Amphetamine-Dextroamphetamine 10 mg PO 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 every 6 hours Disp #*50 Tablet Refills: *1 2. Docusate Sodium 100 mg PO BID: PRN Constipation do not take if having loose stools RX *docusate sodium 100 mg 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills: *1 3. Nitrofurantoin Monohyd (MacroBID) 100 mg PO Q12H Duration: 1 Day Take 2 doses, 12 hours apart, on the day prior to CT cystogram. RX *nitrofurantoin monohyd/m-cryst 100 mg 1 capsule(s) by mouth twice daily Disp #*2 Capsule Refills: *0 4. OxyCODONE (Immediate Release) ___ mg PO Q4H: PRN Pain - Severe Reason for PRN duplicate override: Alternating agents for similar severity Please do not drink or drive while taking this medication RX *oxycodone 5 mg ___ tablet(s) by mouth every 4 hours Disp #*50 Tablet Refills: *0 5. Amphetamine-Dextroamphetamine 10 mg PO BID 6. Multivitamins 1 TAB PO DAILY <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> Placenta Accreta Postpartum Hemorrhage Gestational Diabetes Chronic Hypertension <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Dear Ms. ___, ___ on the birth of your baby! You have recovered well and the team now feels that you are ready to go home. Please follow these instructions below. You were diagnosed with a condition where your placenta adheres tightly to your uterus called placenta accreta. At the time of your Cesarean section, your uterus was also removed because of this condition. Your blood counts were low at this time and you were transfused with blood. Your blood counts then improved without further intervention. There was no concern for ongoing bleeding. You were admitted to the intensive care unit post-operatively but recovered well and were transferred to the floor without complication. We continued to monitor your high blood pressure while you were here. We checked your blood work and this all came back reassuring. We continued the blood pressure medication you were taking during pregnancy called Lebatolol. We also continued to monitor your diabetes. We consulted the ___ diabetes team and they gave us recommendations. 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 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 clinic in 1 week for catheter removal. Please call for an appointment.
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On ___, Ms. ___ was admitted to labor and delivery for a planned cesarean-hysterectomy for suspected placenta accreta at 34w4d. She underwent a diagnostic cystoscopy, bilateral ureteral stent placement, exploratory laparotomy, transfundal cesarean delivery, total hysterectomy, oversew of deserosalized bladder, and bilateral salpingectomy. Please see separate operative reports for full details. Her total EBL was 3500cc. She was given a total of 4 units of pRBCs, 1 unit of FFP, 1 unit of platelets, 600cc from cell saver, and 7 liters of crystalloid. Immediately post op, she was transferred to the FICU intubated given significant resuscitation and concern for difficult extubation from airway edema. Pt was extubated without issue on POD#0 and subsequently called out of the FICU. Her epidural catheter was removed on POD#1. Her labs were trended. Her HCT was trended from 34.5 preop -> 34.9 -> 33.0 -> 32.1. Her coagulation profile remained in the normal limits. She was noted to have poor pain control with oxycodone and tylenol (NSAIDs held given history of gastric bypass) but was noted to have a benign exam with reassuring HCT. She was started on toradol for additional analgesia. Her pain improved with passage of flatus and simethicone. For her history of chronic hypertension, she was continued on labetalol 200mg daily with holding parameters. Her BPs remained in the normal range without symptoms of pre-eclampsia. For her history of GDMA2, her ___ were monitored postpartum and remained at goal. She was seen by ___ during her postpartum course. On POD#4, she was tolerating a regular diet, ambulating independently, and pain was controlled with oral medications. Her foley catheter remained in place given oversew of deserosalized bladder, to be removed on POD#7. She was afebrile with stable vital signs. She was then discharged home in stable condition with postpartum outpatient follow-up scheduled.
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11094943-DS-4
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> latex / gluten <ATTENDING> ___. <CHIEF COMPLAINT> ovarian cancer <MAJOR SURGICAL OR INVASIVE PROCEDURE> exploratory laparotomy, total abdominal hysterectomy, bilateral salpingo-oophrectomy, omentectomy, appendectomy <HISTORY OF PRESENT ILLNESS> The patient is a ___ who, in ___, noticed some fullness in her abdomen. In ___, had a visible protuberance. In ___, she was admitted. She was initially worked up at ___ for progressive dyspnea and malignant pleural effusion and the adnexal mass. However, she was transferred to ___ due to insurance issues. She was then discharged home and the plan was for 3 cycles of neoadjuvant chemotherapy which she received. Her CA125 went from 1500 on admission to 319. She presents today for interval cytoreduction. <PAST MEDICAL HISTORY> OB/GYN: G0 PMH: PNA PSH: none Meds: s/p 3 cycles of ___, ativan qHs All: latex <SOCIAL HISTORY> ___ <FAMILY HISTORY> Family history of lung cancer (heavy smokers) and MI. No gyn, breast or colon cancer. <PHYSICAL EXAM> On admission to ___ ICU: T98 P95 100/51 R17 99% General: well appearing female, intermittently crying in NAD HEENT: Mucous membranes dry Neck: JVP non elevated CV: S1/S2 Regular Rate and Rhythm, no murmurs/gallops appreciated Lungs: Clear to auscultation bilaterally, no wheezes/rales/ronchi. Pleurex cathether in place Abdomen: soft TTP palpation diffusely. dressing over large vertical incision. dressing c/d/i GU: foley Ext: warm, no peripheral edema peripheral pulses 2+ ___ Neuro: AO x3. MAE sensation grossly intact On Discharge: General: NARD, comfortable, well-appearing CV: RRR Lungs: Crackles bilaterally with decreased breath sounds at right base, Pleurex catheter in place Abdomen: Soft, appropriately tender, minimally distended, +BS, no rebound or guarding Incision: Vertical midline incision with staples clean, dry, intact GU: Peripad dry Extremities: Nontender <PERTINENT RESULTS> ___ 08: 30AM BLOOD WBC-5.9 RBC-3.30* Hgb-10.0* Hct-29.5* MCV-90 MCH-30.3 MCHC-33.8 RDW-23.4* Plt Ct-77* ___ 02: 11PM BLOOD WBC-13.9*# RBC-2.60* Hgb-8.1* Hct-23.2* MCV-89 MCH-31.2 MCHC-34.9 RDW-23.8* Plt Ct-56* ___ 06: 56PM BLOOD WBC-11.2* RBC-2.43* Hgb-7.3* Hct-20.9* MCV-86 MCH-30.1 MCHC-35.1* RDW-19.3* Plt Ct-39* ___ 11: 04PM BLOOD WBC-16.3* RBC-3.19*# Hgb-9.8*# Hct-27.6*# MCV-87 MCH-30.7 MCHC-35.4* RDW-17.5* Plt Ct-61*# ___ 03: 17AM BLOOD WBC-7.6# RBC-2.35*# Hgb-7.3*# Hct-20.0*# MCV-85 MCH-31.2 MCHC-36.8* RDW-18.1* Plt Ct-42* ___ 04: 43AM BLOOD WBC-8.6 RBC-2.36* Hgb-7.2* Hct-20.1* MCV-85 MCH-30.5 MCHC-35.9* RDW-18.3* Plt Ct-42* ___ 07: 16AM BLOOD WBC-6.2 RBC-2.23* Hgb-6.9* Hct-19.4* MCV-87 MCH-31.0 MCHC-35.6* RDW-18.5* Plt Ct-44* ___ 10: 39AM BLOOD WBC-6.9 RBC-2.77* Hgb-8.5* Hct-23.9* MCV-86 MCH-30.7 MCHC-35.7* RDW-17.1* Plt Ct-80*# ___ 11: 46AM BLOOD Hct-26.1* ___ 04: 36PM BLOOD WBC-5.6 RBC-3.28* Hgb-10.0* Hct-27.9* MCV-85 MCH-30.5 MCHC-35.8* RDW-16.3* Plt Ct-58* ___ 09: 43PM BLOOD Hct-26.7* ___ 02: 23AM BLOOD WBC-4.4 RBC-3.14* Hgb-9.8* Hct-27.0* MCV-86 MCH-31.2 MCHC-36.2* RDW-16.6* Plt Ct-44* ___ 09: 15AM BLOOD WBC-7.8# RBC-3.26* Hgb-9.9* Hct-27.7* MCV-85 MCH-30.5 MCHC-35.9* RDW-17.1* Plt Ct-79*# ___ 01: 55PM BLOOD WBC-5.8 RBC-3.35* Hgb-10.3* Hct-28.8* MCV-86 MCH-30.7 MCHC-35.7* RDW-16.9* Plt Ct-93* ___ 06: 55AM BLOOD WBC-6.1 RBC-3.42* Hgb-10.6* Hct-29.4* MCV-86 MCH-31.0 MCHC-36.0* RDW-16.9* Plt Ct-85* ___ 06: 40AM BLOOD WBC-4.3 RBC-3.41* Hgb-10.5* Hct-29.9* MCV-88 MCH-30.9 MCHC-35.2* RDW-16.8* Plt Ct-74* ___ 07: 15PM BLOOD ___ PTT-28.0 ___ ___ 11: 04PM BLOOD ___ PTT-27.2 ___ ___ 03: 17AM BLOOD ___ PTT-28.2 ___ ___ 07: 16AM BLOOD ___ PTT-27.6 ___ ___ 10: 39AM BLOOD ___ PTT-30.5 ___ ___ 02: 23AM BLOOD ___ PTT-71.2* ___ ___ 01: 55PM BLOOD ___ PTT-27.1 ___ ___ 06: 55AM BLOOD ___ PTT-27.2 ___ ___ 06: 40AM BLOOD ___ PTT-27.2 ___ ___ 07: 15PM BLOOD ___ ___ 03: 17AM BLOOD ___ 07: 16AM BLOOD ___ 01: 55PM BLOOD ___ ___ 06: 55AM BLOOD ___ ___ 06: 40AM BLOOD ___ ___ 07: 16AM BLOOD ___ ___ 02: 11PM BLOOD Glucose-127* UreaN-8 Creat-0.7 Na-137 K-3.8 Cl-107 HCO3-23 AnGap-11 ___ 06: 56PM BLOOD Glucose-180* UreaN-9 Creat-0.7 Na-136 K-4.4 Cl-106 HCO3-23 AnGap-11 ___ 11: 04PM BLOOD Glucose-136* UreaN-12 Creat-0.8 Na-139 K-4.9 Cl-106 HCO3-23 AnGap-15 ___ 03: 17AM BLOOD Glucose-111* UreaN-12 Creat-0.8 Na-141 K-4.3 Cl-109* HCO3-25 AnGap-11 ___ 10: 39AM BLOOD Glucose-82 UreaN-11 Creat-0.8 Na-142 K-3.7 Cl-110* HCO3-24 AnGap-12 ___ 02: 23AM BLOOD Glucose-79 UreaN-9 Creat-0.7 Na-144 K-3.7 Cl-110* HCO3-24 AnGap-14 ___ 06: 40AM BLOOD Glucose-80 UreaN-6 Creat-0.6 Na-139 K-3.5 Cl-104 HCO3-27 AnGap-12 ___ 11: 04PM BLOOD ALT-154* AST-206* LD(LDH)-623* AlkPhos-62 TotBili-1.2 ___ 03: 17AM BLOOD ALT-282* AST-368* LD(LDH)-649* AlkPhos-49 TotBili-0.9 ___ 02: 23AM BLOOD ALT-237* AST-354* AlkPhos-51 TotBili-0.8 ___ 06: 55AM BLOOD ALT-196* AST-180* ___ 06: 40AM BLOOD ALT-129* AST-83* ___ 02: 11PM BLOOD Calcium-8.2* Phos-3.7 Mg-1.9 ___ 06: 56PM BLOOD Calcium-7.4* Phos-4.5 Mg-1.6 ___ 11: 04PM BLOOD Calcium-9.1 Phos-4.9* Mg-1.7 ___ 03: 17AM BLOOD Calcium-8.1* Phos-4.4 Mg-2.2 ___ 10: 39AM BLOOD Calcium-8.7 Phos-3.7 Mg-2.0 ___ 02: 23AM BLOOD Calcium-8.0* Phos-3.0 Mg-1.6 ___ 06: 55AM BLOOD Calcium-8.5 Phos-2.7 Mg-1.7 ___ 06: 40AM BLOOD Calcium-8.5 Phos-3.1 Mg-1.7 ___ 03: 17AM BLOOD Hapto-49 ___ 03: 42AM BLOOD ___ pO2-34* pCO2-44 pH-7.36 calTCO2-26 Base XS-0 Comment-GREEN TOP ___ 12: 35PM BLOOD ___ pH-7.46* ___ 03: 42AM BLOOD freeCa-1.11* ___ 12: 35PM BLOOD freeCa-1.18 ___ 11: 04 pm BLOOD CULTURE Source: Venipuncture. Blood Culture, Routine (Pending): ___ 3: 17 am BLOOD CULTURE Blood Culture, Routine (Pending): ___ 11: 04 pm MRSA SCREEN **FINAL REPORT ___ MRSA SCREEN (Final ___: No MRSA isolated. <MEDICATIONS ON ADMISSION> The Preadmission Medication list is accurate and complete. 1. Ondansetron 4 mg PO PRN Before chemo 2. Lorazepam 0.5 mg PO PRN Pre and post chemo <DISCHARGE MEDICATIONS> 1. Lorazepam 0.5 mg PO PRN Pre and post chemo 2. Ondansetron 4 mg PO PRN Before chemo 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. Ibuprofen 600 mg PO Q6H: PRN pain RX *ibuprofen 600 mg 1 tablet(s) by mouth every six (6) hours Disp #*60 Tablet Refills: *0 5. OxycoDONE (Immediate Release) ___ mg PO Q4H: PRN pain RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours Disp #*60 Tablet Refills: *0 6. Simethicone 40-80 mg PO QID: PRN gas pain RX *simethicone 80 mg 1 tablet by mouth four times a day Disp #*60 Tablet Refills: *0 <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> ovarian cancer <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Dear 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. * If you have staples, they will be removed at your follow-up visit. To reach medical records to get the records from this hospitalization sent to your doctor at home, call ___. Call your doctor ___ ___ for: * fever > 100.4 * severe abdominal pain * difficulty urinating * vaginal bleeding requiring >1 pad/hr * abnormal vaginal discharge * redness or drainage from incision * nausea/vomiting where you are unable to keep down fluids/food or your medication * chest pain or difficulty breathing
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Ms. ___ was admitted to the gynecology oncology service after undergoing interval debulking including total abdominal hysterectomy, bilateral salpingo-oophrectomy, omentectomy and appendectomy for stage 4 ovarian cancer. Please see the operative report for full details. Immediately postoperatively, she was transferred to the ___ ___ Care Unit for hypotension, blood loss anemia and thrombocytopenia. Her ICU course is detailed as follows. # Hypotension: The patient became hypotensive post-operatively with a nadir of ___, responsive to transient vasopressor and colloid and crystalloid resuscitiation. This was thought to be due to anesthesia, fluid shifts/third spacing, bleeding (see below). Her blood pressures remained stable in the ICU, with no further pressor requirement, but intermittent need for transfusion. # Acute blood loss anemia: Her hematocrit declined from 29.5 to a nadir of 19.4. Her hematocrit did not respond to initialy transfusions, most likely secondary to postoperative oozing combined with fluid shifts. Hemolysis labs were reassuring. Serial hematocrits were stable on postoperative day #1. She received a total of 8 units of pRBCs and 2 of FFP to obtain a goal hematocrit of > 25. # Thromboyctopenia: Thrombocytopenia was thought to be ikely secondary to recent neoadjuvant chemotherapy. Again, hemolysis labs were reassuring. She received a total of 3 units of platelets. # Transminitis: Liver function tests were noted to be elevated to a peak of ALT of 282 and AST of 368, possibly related to transient ischemia in the setting of hypotensive episode vs. chemotherapy-related effects. # Postoperative care: Her pain was controlled with a dilaudid PCA. She tolerated sips without nausea/vomiting while in the ICU. She received 2 doses of kefzol postoperatively. She was transferred to the floor on postoperative day #2. Upon transfer to the floor, her pain was controlled with a dilaudid PCA. Her diet was advanced without difficulty. On postoperative day #3, she was transitioned to oral oxycodone and motrin for pain control. Her urine output was adequate so her Foley catheter was removed and she voided spontaneously. She received lovenox for venous thromboembolism prevention beginning on postoperative day #3. Her hematocrit and platelets remained stable throughout the remainder of her hospitalization. Her liver function tests continued to improve. 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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| 598
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11097411-DS-5
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Patient recorded as having No Known Allergies to Drugs <ATTENDING> ___. <CHIEF COMPLAINT> left sided abdominal pain, left adnexal mass <MAJOR SURGICAL OR INVASIVE PROCEDURE> exploratory laparotomy, bilateral salpingo-oophorectomy, appendectomy, omental biopsy, washings, cystoscopy for 30cm left adnexal mass. <HISTORY OF PRESENT ILLNESS> ___ yo ___ postmenopausal white F with h/o umbilical hernia repair who was in her usual state of health until approximately two months ago. She experienced a 15 to 20 minute episode of left sided abdominal pain. The pain resolved spontaneously. She denies associated nausea, vomiting, fevers, chills or vaginal bleeding. She had a similar episode about two weeks later, which lasted approximately 30 minutes. Pelvic imaging was performed (see below) which revealed a large pelvic mass. Outside hospital imaging: Pelvic u/s ___) ___: large complex cystic and solid mass superior to uterus which is difficult to get an accurate measurement --> measures at least 22.5 x 17.2 x 22 cm; L ovary not identified; normal R ovary; uterus anteverted measuring 10.1 x 4.7 x 5.2 cm. CT abd/pelvis w/ ___ ___: large pelvic mass of mixed solid and cystic density measuring 20 x 33 x 26 cm, most likely an ovarian neoplasm, trace fluid in cul-de-sac, uterus normal, R adnexa normal, bowel displaced by large pelvic mass but otherwise normal. The patient reports continued mild abdominal pressure and discomfort. She has been able to tolerate a regular diet. Denies nausea, vomiting, fevers, chills. Denies vaginal bleeding. She has no family history of breast or ovarian malignancy. Her last mammogram was in ___ and normal. <PAST MEDICAL HISTORY> PGYNH: Menarche age ___ LMP: ___ No h/o abnormal Pap tests Last Pap: ___ - normal per pt No h/o STIs Sexually active: yes Sexual preference: opposite Current contraception: s/p tubal sterilization Last mammogram: ___ - negative per pt POBH: ___ SAB x ___ SVD ___ SVD ___ SVD - twin A, c-section - twin B PMH: 1) obesity PSH: 1) umbilical hernia repair w/ mesh 2) lipoma excision - L arm 3) c-section <SOCIAL HISTORY> ___ <FAMILY HISTORY> No breast, colon, or gynecologic malignancy. <PHYSICAL EXAM> <PHYSICAL EXAM> Weight 304 lbs Height 5'8" BP 130/86 BMI 46 General appearance: in NAD Psych: alert and oriented x 3, mood and affect appropriate Neck: No masses; no thyromegaly or nodules Lymphatic: no palpable neck or groin lymphadenopathy Lungs: clear to auscultation bilaterally, good inspiratory effort bilaterally, no wheezing CV: RRR, no murmurs/rubs/gallops Abd: soft, obese, mildly tender L mid-abdomen, non-distended, no masses or hepatosplenomegaly appreciated, no hernias; well-healed ___ and periumbilical incisions Extremities: no venous disease, no lesions, good perfusion, no edema Skin: intact, no skin changes or lesions detected Pelvic: Normal external female genitalia Urethral meatus normal in appearance Bladder and urethra normal in appearance Normal vaginal mucosa, no vaginal lesions Cervix without abnormal discharge or lesions, midline Bimanual: uterus non-palpable, large cystic mass filling pelvis Rectovaginal: deferred <PERTINENT RESULTS> Tumor markers from ___: CA-125 (35), CEA (1.1), CA ___ (10) <MEDICATIONS ON ADMISSION> CITALOPRAM - (Prescribed by Other Provider) - 20 mg Tablet - 1 Tablet(s) by mouth once a day <DISCHARGE MEDICATIONS> 1. Oxycodone-Acetaminophen ___ mg Tablet Sig: ___ Tablets PO Q4H (every 4 hours) as needed for pain. Disp: *50 Tablet(s)* Refills: *0* 2. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain: please take medication with food. . Disp: *60 Tablet(s)* Refills: *0* 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation. Disp: *60 Capsule(s)* Refills: *2* <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> Left adnexal mass: intraoperative frozen section: benign mucinous cystadenoma; final pathology pending. <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Please follow the post-surgery instruction provided by Dr. ___.
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Ms. ___ was admitted after undergoing exploratory laparotomy, bilateral salpingo-oophorectomy, appendectomy, omental biopsy, washings, cystoscopy for 30cm left adnexal mass. Pelvic exam under anesthesia revealed a fullness within the pelvis, but no discrete lesions or nodularity. Intraoperative findings included enlarged cystic mass that was arising from the left adnexa, smooth on its surface without any papillary excrescences, and the contents of the cystic mass revealed mucinous fluid. The cyst was multiseptated, with one portion containing 6.5 L of greenish-yellow mucinous material and the ___ portion containing 2 L of clear, colorless mucinous contents. Frozen section by pathology revealed a complex mucinous neoplasm, likely benign, without evidence of borderline or malignant histology. The right fallopian tube and right ovary were normal. The left fallopian tube was noted to be extremely stretched out over the large cystic mass. The uterus was normal in size and unremarkable. The appendix was noted to be very small without evidence of nodularity or pathology. Cystoscopy performed at the end of the procedure revealed normal bladder mucosa. There were bilateral ureteral orifices identified with bilateral indigo ___ jets observed. Please see operative note by Dr. ___ complete details. Her post-operative course was uncomplicated and received routine post-operative care. Her home medication was restarted on post-op day#1. She was discharged on post-operative day #2 in stable condition: afebrile, able to eat regular food, under adequate pain control with oral medications, and ambulating and urinating without difficulty.
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11101393-DS-17
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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 laprascopic hysterectomy with bilateral salpingectomy and cystoscopy <HISTORY OF PRESENT ILLNESS> ___ yo G0 with no significant PMH. PSH significant for open apy age ___. ___ presented to her PCP with complaints of menorrhagia. A PUS ___ notes "uterus is anteverted and measures 8.1 x 3.7 x 7.7 cm. Multiple fibroids are identified the largest which is exophytic and fundal measuring 7.7 x 7.9 x 7.9. Smaller intramural fibroids are located posteriorly, one of which distorts the endometrium with a submucosal component measuring 3.6 x 3.2 x 3.7 cm. The endometrium is homogenous and measures 11 mm. The right ovary is unremarkable. Within the left ovary, there is a 1.9 x 2.8 x 3.1 cm complex cyst with internal echoes and septations without abnormal vascularity most compatible with a hemorrhagic cyst. There isnofree fluid." A full panel of labs indicates no anemia or thyroid dysfunction. ___ presents in consulation to discuss surgical managment of same. <PAST MEDICAL HISTORY> OBSTETRICAL HISTORY: G0 GYNECOLOGICAL HISTORY: Menstrual Hx: ___ PAP Hx: No h/o abnormal Pap smears; Last Pap ___ neg hpv neg ___ Hx: ___ neg STI Hx: denies Sexually active: yes, condoms PAST MEDICAL HISTORY: none PAST SURGICAL HISTORY: open apy age ___ ___ <SOCIAL HISTORY> ___ <FAMILY HISTORY> FAMILY HISTORY: no gi gu ca mother died of stroke age ___, Factor V ___ (hetero?) Sister and Aunt both FVL + both with sig clot history (PE, DVT) <PHYSICAL EXAM> PHYSICAL EXAM: BP: 115/70 Heart Rate: 64 Weight: 124 Height: 62.20 (Patient Reported) BMI: 22.5 LMP: ___ General: well appearing female in no apparent distress, alert and oriented HEENT: normocephalic, atraumatic, anicteric sclera Neck: supple, FROM, no thyromegaly or nodules Lymphatic: no palpable neck lymphadenopathy Back: no CVA tenderness Lungs: clear to auscultation bilaterally, good inspiratory effort, no wheezing/rales/rhonchi CV: regular rate and rhythm, no murmurs/rubs/gallops Abd: soft, +bowel sounds, non-tender, non-distended, no R/G Extremities: no clubbing/cyanosis/edema Pelvic: Skin- grossly normal external female genitalia SSE- nl cervix at ML, no unusual blding/lesions/discharge normal vaginal vault BME- large mobile fibroid uterus, no adnexal masses or tenderness Pelvic MS ___- no obturator or levator muscle tenderness Rectovaginal Exam: deferred Upon discharge: Vital signs stable General: well appearing, no acute distress Abdomen: soft, nondistended, incisions clean, dry, and intact <PERTINENT RESULTS> Intraoperative findings: enlarged uterus, normal tubes, left ovary with small cyst. normal cysto with bilateral jets <MEDICATIONS ON ADMISSION> Vitamin D <DISCHARGE MEDICATIONS> 1. Enoxaparin Sodium 40 mg SC DAILY Start: ___, First Dose: Next Routine Administration Time 2. Ibuprofen 600 mg PO Q6H: PRN pain RX *ibuprofen 600 mg 1 tablet(s) by mouth every six hours Disp #*50 Tablet Refills: *1 3. Oxycodone-Acetaminophen (5mg-325mg) ___ TAB PO Q4H: PRN pain Do not drive while taking RX *oxycodone-acetaminophen 5 mg-325 mg ___ tablet(s) by mouth every 4 hours Disp #*50 Tablet Refills: *0 4. Docusate Sodium 100 mg PO BID constipation RX *docusate sodium 100 mg 1 tablet(s) by mouth twice daily Disp #*50 Tablet 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 bath tubs for 6 weeks. * If you have steri-strips, leave them on. They will fall off on their own or be removed during your followup visit. * If you have staples, they will be removed at your follow-up visit. Call your doctor for: * fever > 100.4 * severe abdominal pain * difficulty urinating * vaginal bleeding requiring >1 pad/hr * abnormal vaginal discharge * redness or drainage from incision * nausea/vomiting where you are unable to keep down fluids/food or your medication To reach medical records to get the records from this hospitalization sent to your doctor at home, call ___.
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The patient was admitted to the gynecology service for her procedure. Her intraoperative course was uncomplicated. Given a family history of VTEs, the patient was begun on lovenox postoperative day #1. Upon meeting postoperative milestones, the patient was discharged home in stable condition with plan for anticoagulation with lovenox for two weeks.
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11101737-DS-3
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Patient recorded as having No Known Allergies to Drugs <ATTENDING> ___. <CHIEF COMPLAINT> Upper abd pain/back pain <MAJOR SURGICAL OR INVASIVE PROCEDURE> ERCP ___ exchange Percutaneous cholecystotomy <HISTORY OF PRESENT ILLNESS> ___ yo G2P1 @ ___ ___ ___ with a h/o cholelithiasis and stent placement in ___ presents to the ED with c/o sharp epigastric pain and upper back pain. Pt underwent ERCP and attempted stent removal on ___. Met pt prior to ERCP on ___ and performed FHR check in pre-op area. Pt has had constant RUQ and epigastric pain since ___ after the procedure this am. ERCP report states biliary stent removed, stone extracted, stent placed. Plan is to repeat ERCP for stent removal after delivery and consider cholecystectomy. Pt received Ampicillin ___. Denies f/c. No n/v. Pain is localized to epigastrium and radiates to the back. No contractions, LOF, VB. Notes active FM. PNC: *) Dating: ___ ___ by LMP c/w early U/S *) Labs: B+/Ab-/RI/RPRNR/HbsAg-/GBS unk *) U/S: nl FFS *) h/o cholelithiasis with large CBD stone: s/p ERCP and stent placement ___. Followed by GI. Underwent ERCP and stent removal and replacement on ___. <PAST MEDICAL HISTORY> ObHx: -SVD @ term, ___, no complications GynHx: None PMH: Cholethiasis as above PSH: None <SOCIAL HISTORY> ___ <FAMILY HISTORY> non-contributory <PHYSICAL EXAM> PE: 98.3, HR 70, BP 130/93, RR 22, 97%Ra Pt jaundiced, appears unwell and uncomfortable CTA bilaterally RRR Abd soft, tender at epigastrium and RUQ, ND, no uterine tenderness, no rebound/guarding No ___ edema, NT FHR 153 <PERTINENT RESULTS> ___ 07: 50AM ___ PTT-28.5 ___ ___ 07: 50AM PLT COUNT-512*# ___ 07: 50AM WBC-10.5 RBC-3.68* HGB-10.8* HCT-32.3* MCV-88 MCH-29.5 MCHC-33.6 RDW-12.3 ___ 07: 50AM LIPASE-32 ___ 07: 50AM ALT(SGPT)-23 AST(SGOT)-15 ALK PHOS-141* TOT BILI-0.2 DIR BILI-0.1 INDIR BIL-0.1 ___ 11: 00PM PLT COUNT-580* ___ 11: 00PM NEUTS-81.8* LYMPHS-13.8* MONOS-3.8 EOS-0.3 BASOS-0.2 ___ 11: 00PM WBC-9.8 RBC-3.68* HGB-11.1* HCT-32.0* MCV-87 MCH-30.2 MCHC-34.7 RDW-13.3 ___ 11: 00PM LIPASE-39 ___ 11: 00PM ALT(SGPT)-40 AST(SGOT)-44* ALK PHOS-209* AMYLASE-60 TOT BILI-0.5 ___ 11: 00PM GLUCOSE-90 UREA N-7 CREAT-0.5 SODIUM-135 POTASSIUM-4.2 CHLORIDE-101 TOTAL CO2-23 ANION GAP-15 ___ 05: 58AM PLT SMR-HIGH PLT COUNT-536* ___ 05: 58AM NEUTS-86* BANDS-0 LYMPHS-8* MONOS-6 EOS-0 BASOS-0 ___ MYELOS-0 ___ 05: 58AM WBC-11.9* RBC-3.61* HGB-11.1* HCT-31.9* MCV-88 MCH-30.8 MCHC-34.9 RDW-12.5 ___ 05: 58AM CALCIUM-8.4 PHOSPHATE-3.3 MAGNESIUM-1.8 ___ 05: 58AM LIPASE-36 ___ 05: 58AM ALT(SGPT)-38 AST(SGOT)-36 LD(LDH)-183 AMYLASE-60 TOT BILI-0.5 ___ 05: 58AM GLUCOSE-83 UREA N-7 CREAT-0.4 SODIUM-136 POTASSIUM-4.5 CHLORIDE-103 TOTAL CO2-23 ANION GAP-15 ___ RUQ ultrasound INDICATION: ___ female status post ERCP, presenting with abdominal pain. COMPARISONS: ___. FINDINGS: The liver is normal in echotexture. No focal lesion is identified. Images of the head and body of the pancreas appear unremarkable. The gallbladder is significantly distended, and this is new compared to the study of ___ study. The gallbladder is filled with echogenic material and debris, which appears non-vascularized. The wall is mildly thickened measuring 5 mm, and there is evidence of both wall edema and pericholecystic fluid. Overall, this is concerning for acute cholecystitis. The sonographic ___ sign is present. The common bile duct is dilated measuring 10 mm. Hyperechoic areas in the lower CBD are concerning for possible sludge or stones. The most discrete echogenic focus in the lower CBD measures approximately 7 mm. IMPRESSION: 1. Newly distended gallbladder with wall edema, pericholecystic fluid, filled with echogenic material, is highly concerning for acute cholecystitis and appears new compared to ___. 2. Possible filling defect within the lower CBD. Please note the biliary stent was not definitely visualized on this examination. ___ RUQ ultrasound Final Report INDICATION: ___ woman with 28 weeks pregnancy, status post ERCP stent exchange with increasing right upper quadrant pain and rising bilirubin. Evaluate for stent placement. COMPARISON: ___. FINDINGS: The gallbladder is markedly distended with significant gallbladder wall edema, measuring up to 4.1 mm. There is large amount of sludge within the gallbladder. There is intra- as well as extra-hepatic biliary ductal dilation with the CBD measuring up to 13 mm. An ERCP stent was partially visualized within the CBD, however, its distal and more proximal course were not seen. Portal vein is patent with forward flow. No hepatic masses or lesions were noted IMPRESSION: 1. Markedly distended, sludge-filled gallbladder with wall edema and irregularity suggesting sloughing, again concerning for acute cholecystitis. 2. Associated intra- and extra- hepatic ductal dilation with CBD measuring up to 13 mm. The ERCP stent is partially visualized within the CBD, however, its entire course was not seen. ___ RUQ US-guigeg percutaneous cholecystostomy tube placement CLINICAL HISTORY: Patient with obstructed gallbladder containing sludge and stones. Inability to clear with stent placement by ERCP. Continued pain. Request gallbladder drainage. PROCEDURE: Ultrasound-guided percutaneous cholecystostomy tube placement. TECHNIQUE: The patient was informed of the procedural technique and its risks including hemorrhage, infection, bile leak, and liver injury. The patient gave written consent with the aid of an interpreter. The patient's right lower quadrant was prepared and draped in the usual sterile fashion. The skin was cleaned using Betadine. 1% lidocaine was administered at the site of the skin for appropriate access to the gallbladder. A small skin ___ was made in the skin and then using ultrasound guidance an 8 ___ ___ catheter was advanced into the gallbladder with a single pass. The needle was removed and the catheter was advanced off of the stiff stylette into the gallbladder but initially cloudy sanguineous fluid was removed followed by brown bile and then subsequently followed by more murky bile. The catheter was pigtailed and secured to the skin with a StatLock. The catheter was placed to drainage. There were no immediate complications. During the procedure, the patient was given moderate conscious sedation. Moderate sedation was provided by administering divided doses of Versed and fentanyl with a total of 50 mcg of fentanyl and 1.5 mg of Versed administered throughout the total intra-service time of 45 minutes during which the patient's hemodynamic parameters were continuously monitored by two physicians and ___ nurse trained in conscious sedation. FINDINGS: On pre-procedural imaging, the gallbladder was again identified containing tumefactive sludge. There is gallbladder wall edema. Subsequent images show the catheter with needle in place within the gallbladder and then the pigtail catheter within the gallbladder which has decreased in size after aspiration. IMPRESSION: Successful placement of 8 ___ percutaneous cholecystostomy tube within the gallbladder. Heterogeneous fluid drained with substantial murky bile seen. Post-drainage imaging showed residual tumefactive sludge within the gallbladder, decreased in size. Samples were sent to the lab for microbiology analysis. ___ RUQ US: HISTORY: Status post percutaneous cholecystostomy placement ___, with drain not draining, in patient with worsening abdominal pain. Evaluate biliary tree. FINDINGS: Right upper quadrant ultrasound demonstrates the common duct to measure approximately 1.1 cm in diameter, with a catheter/stent seen within this. No significant intrahepatic biliary ductal dilatation is seen, and when compared to yesterday's ultrasound, caliber appears slightly smaller. Evaluation of the gallbladder again demonstrates a markedly abnormal appearance. The gallbladder is less distended on the current examination than it was yesterday, with a thickened gallbladder wall and a large amount of internal debris/sludge also seen. Cholecystostomy catheter is seen within the gallbladder. Limited assessment of the liver is unremarkable. IMPRESSION: 1. Percutaneous cholecystostomy and biliary stent in expected locations. 2. Interval decompression of the abnormal appearing gallbladder, with a small amount of biliary fluid seen mildly distending it, and large amount of internal debris/sludge present. <MEDICATIONS ON ADMISSION> PNV <DISCHARGE MEDICATIONS> 1. Normal Saline Flush 0.9 % Syringe Sig: One (1) 10mL pre-filled Injection once a day: Flush drain once a day. Disp: *qs 1 month 10mL pre-filled syringes* Refills: *3* 2. Amoxicillin-Pot Clavulanate 500-125 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp: *18 Tablet(s)* Refills: *0* 3. Percocet ___ mg Tablet Sig: ___ Tablets PO every four (4) hours as needed for pain. Disp: *20 Tablet(s)* Refills: *0* <DISCHARGE DISPOSITION> Home With Service Facility: ___ <DISCHARGE DIAGNOSIS> Cholelithiasis, obstructed gallbladder Pregnant <DISCHARGE CONDITION> Good <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Rest at home. Eat a bland diet. Stay hydrated. Call your doctor if you have increasing pain, inability to tolerate food or drinks, or have nausea or vomiting. Also call if you have contractions, bleeding, leaking fluid, or decreased fetal movement. For any drain questions, contact: ___, ___ Nurse Practitioner, ___ Radiology & Tumor Ablation ___ ___ Phone: ___ Page: ___ Fax: ___
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Patient is a ___ G2P1 with EDC ___ with h/o cholelithiasis and recent ERCP stent exchange on ___ admitted to the antepartum service with abdominal pain and LFT elevations. RUQ ultrasound on ___ showed a newly distended gallbladder with wall edema, pericholecystic fluid, and filled with echogenic material, which was highly concerning for acute cholecystitis. A possible filling defect was noted within the lower CBD. The biliary stent was not definitely visualized on this examination. Patient's overall clinical presentation was most consistent with obstructed gallbladder, not felt to be acutely infected. After consultation with general surgery, ERCP service, as well as interventional radiology, decision was made to proceed with ultrasound-guided percutaneous transhepatic cholecystotomy for obstructed gallbladder. Patient underwent this procedure on ___ without complication. There was no evidence of cholangitis, perforation, pancreatitis. The patient continued on IV Unasyn after the procedure and was to complete a full week of antibiotics with augmentin. Of note, the bile fluid culture was positive for rare Strep Viridans. After the procedure, the patient's epigastric pain resolved, LFT's normalized, and she was advanced to regular diet. The patient began experiencing some new pain at the drain site, but declined any pain medication. There was a question of possible blocked drain on ___, but the repeat ultrasound showed interval decompression of the abnormal appearing gallbladder, with a small amount of biliary fluid seen mildly distending it, and large amount of internal debris/sludge present. The patient was discharged home with plan to keep the percutaneus cholecystostomy in place until delivery and remove immediately once postpartum. General surgery consultation with Dr. ___ ___ recommended plan for laparoscopic cholecystectomy 6 ___ postpartum. *) FWB: Fetal testing was reassuring with an EFW 1180g (50%) and BPP of ___ on ___. One small dilated but physiologically dilated colonic loop was noted on a routine ATU ultrasound with the plan to have follow up in approximately one week in radiology to make sure that this is not progressing and that this is still physiologic. Various consultations during this hospital course: ERCP: Dr. ___ and Dr. ___ (fellow) General Surgery: Dr. ___ radiology: Dr. ___ there be any drain questions, contact: ___, NP Nurse Practitioner, ___ Radiology & Tumor Ablation ___ ___ Phone: ___ Page: ___ Fax: ___
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11102129-DS-2
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Codeine <ATTENDING> ___ <CHIEF COMPLAINT> vaginal prolapse and urinary incontinence <MAJOR SURGICAL OR INVASIVE PROCEDURE> ___ vault suspension, I-STOP sling, anterior & posterior colporrhaphy, cystoscopy <HISTORY OF PRESENT ILLNESS> The patient is a ___ gravida 4, para 4 who was referred to me by Dr. ___. The patient presented complaining of vaginal prolapse. She was examined and found to have a second-degree cystocele, second-degree vault prolapse, second-degree uterine prolapse, a third- degree posterior enterocele, and a third-degree rectocele. The patient was referred for multichannel urodynamics testing and this showed that she had severe stress urinary incontinence (intrinsic sphincter deficiency). The patient was counseled extensively regarding the findings of my evaluation. She elected to proceed with surgical management. The risks, benefits, and alternatives to surgery were explained to the patient. <PAST MEDICAL HISTORY> 1.HTN 2.Hypercholesterolemia 3.GERD 4.Osteoporosis 5. Recent URI PAST SURGICAL HISTORY 1.Lap tubal ligation 2.Right knee surgery ___ (___) 3. Cataract ___ PAST OB HISTORY G4P4004 Vaginal: 4 No Forceps or Vacuum. Largest Vaginal delivery: 7 lbs. C-Section: None PAST GYN HISTORY She denies having had Chlamydia, Gonorrhea, Syphilis, Genital Herpes, Trichomonas, Human Papilloma Virus (HPV) or HIV] She denies having an abnormal Pap test and her last one was in ___ by Dr. ___. She denies having an abnormal Mammogram and her last one was in ___ She is scheduled for a colonoscopy was next week. She has been Postmenopausal x ___ years She denies using hormone therapy She denies using vaginal estrogen cream. She post-menopausal bleeding. <SOCIAL HISTORY> ___ <FAMILY HISTORY> Her family history is significant for a history of daughter dying of lung CA and is otherwise unremarkable. <PHYSICAL EXAM> On arrival to floor: VS HR 97 100/56 15 98% on 3L NC I/O in OR 1000cc IVF, 38cc UOP, 250cc EBL I/O in PACU LR @125 + 1000cc bolus, ___ UOP, bladder scan: 0cc NAD, +pallor, +diaphoresis RRR CTAB Abd soft, ND, NT, +ecchymosis on mons, foley in place, spotting on peripad Ext no edema, no calf tenderness <PERTINENT RESULTS> ___ 06: 25PM BLOOD WBC-20.6*# RBC-2.80*# Hgb-8.4*# Hct-24.6*# MCV-88 MCH-29.9 MCHC-34.0 RDW-13.6 Plt ___ ___ 05: 45AM BLOOD WBC-12.3* RBC-2.36* Hgb-7.0* Hct-20.7* MCV-88 MCH-29.9 MCHC-34.0 RDW-13.7 Plt ___ ___ 12: 00PM BLOOD WBC-15.0* RBC-3.36* Hgb-9.9* Hct-29.4* MCV-88 MCH-29.6 MCHC-33.8 RDW-14.3 Plt ___ ___ 08: 50PM BLOOD Na-137 K-4.2 Cl-104 ___ 06: 25PM BLOOD CK(CPK)-62 ___ 05: 45AM BLOOD CK(CPK)-75 ___ 06: 25PM BLOOD CK-MB-2 cTropnT-<0.01 ___ 05: 45AM BLOOD CK-MB-3 cTropnT-<0.01 ___ 05: 45AM BLOOD Calcium-8.2* Phos-4.1 Mg-1.6 <MEDICATIONS ON ADMISSION> ALENDRONATE 70mg daily, LISINOPRIL 40mg daily, OMEPRAZOLE 20mg daily, SIMVASTATIN 20mg daily <DISCHARGE MEDICATIONS> 1. acetaminophen 500 mg Tablet Sig: ___ Tablets PO Q6H (every 6 hours) as needed for pain: maximum daily Tylenol (acetaminophen) is 4000mg. Disp: *60 Tablet(s)* Refills: *0* 2. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. Disp: *50 Tablet(s)* Refills: *0* 3. lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 4. nitrofurantoin (macrocryst25%) 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) for 14 days. Disp: *28 Capsule(s)* Refills: *0* 5. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 6. Pyridium 200 mg Tablet Sig: One (1) Tablet PO every eight (8) hours as needed for dysuria for 3 days. Disp: *9 Tablet(s)* Refills: *0* 7. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day. Disp: *60 Capsule(s)* Refills: *2* <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> pelvic organ prolapse urinary incontinence <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 > 101 * severe abdominal or vaginal 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 or until instructed by your doctor. * You may eat a regular diet. Incision care: * You may shower and allow soapy water to run over incision; no scrubbing of incision. No bath tubs for 6 weeks.
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Ms. ___ underwent an ___ vault suspension, I-STOP sling, AP colporrhaphy, cystoscopy for SUI/ISD, vault prolapse, and rectocele/enterocle. Please see operative report for details of the surgery. Postoperatively she complained of nausea and diaphoresis in the recovery room. An EKG was obtained which showed no changes from prior and cardiac enzymes were negative x 2. Her symptoms were attributed to a post-anesthesia effect and resolved spontaneously. She initially had elevated potassium to 5.2 which normalized to 4.2 upon repeat without intervention. Postoperatively she was also monitored for low urine output and a decreasing hematocrit from 33.2 to 20.7 postoperatively. Her urine output improved after a 2L bolus in the recovery room. For her decreasing hematocrit, her exam and VS did not indicate peritoneal bleed and she was hemodynamically stable. Toradol was held, Motrin was discontinued, and she was transfused a total of 4 units of packed red blood cells with a response in hematocrit to 29.4. Her anemia was attributed to a possible postoperative retropubic hematoma which was self-limited, and she clinically stabilized and was asymptomatic. She received 10mg IV lasix x 1 due to concern for volume overload given multiple transfusions and diuresed appropriately. She failed her voiding trial on postoperative day 2 and a foley was replaced. She was discharged on postoperative day #2 in good condition: she was hemodynamically stable, her pain well-controlled on oral medications, ambulating and on a regular diet, with good urine output through her foley. She was given leg-bag training and instructions to follow up with Dr. ___ for foley removal.
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| 382
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11109610-DS-4
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> endometriosis and fibroid uterus <MAJOR SURGICAL OR INVASIVE PROCEDURE> robotic-assisted laparoscopic bilateral ovarian cystectomy, right salpingo-oophorectomy, and myomectomy for endometriosis and fibroid uterus <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> ___ 06: 54PM GLUCOSE-116* UREA N-9 CREAT-0.6 SODIUM-136 POTASSIUM-4.0 CHLORIDE-101 TOTAL CO2-28 ANION GAP-11 ___ 06: 54PM CALCIUM-8.5 PHOSPHATE-3.2 MAGNESIUM-1.8 ___ 06: 54PM WBC-19.9* RBC-3.05* HGB-7.8* HCT-23.8* MCV-78* MCH-25.6* MCHC-32.8 RDW-18.9* RDWSD-53.2* ___ 06: 54PM NEUTS-79.2* LYMPHS-13.2* MONOS-6.9 EOS-0.0* BASOS-0.1 IM ___ AbsNeut-15.74* AbsLymp-2.63 AbsMono-1.37* AbsEos-0.00* AbsBaso-0.01 ___ 06: 54PM PLT COUNT-317 ___ 08: 20AM WBC-18.8* RBC-3.11* HGB-7.5* HCT-23.6* MCV-76* MCH-24.1* MCHC-31.8* RDW-19.3* RDWSD-52.6* ___: 20AM NEUTS-86.1* LYMPHS-7.8* MONOS-5.3 EOS-0.0* BASOS-0.2 IM ___ AbsNeut-16.20*# AbsLymp-1.47 AbsMono-0.99* AbsEos-0.00* AbsBaso-0.03 ___ 08: 20AM PLT COUNT-362 ___ 12: 05AM WBC-24.4*# RBC-3.19* HGB-7.7* HCT-24.4* MCV-77* MCH-24.1* MCHC-31.6* RDW-19.4* RDWSD-53.1* ___ 12: 05AM PLT COUNT-361 ___ 07: 30PM TYPE-ART PO2-111* PCO2-41 PH-7.33* TOTAL CO2-23 BASE XS--4 ___ 07: 30PM GLUCOSE-208* LACTATE-3.3* NA+-135 K+-4.1 CL--107 TCO2-21 ___ 07: 30PM HGB-8.1* calcHCT-24 O2 SAT-97 ___ 07: 30PM freeCa-1.05* ___ 05: 45PM TYPE-ART PO2-223* PCO2-60* PH-7.21* TOTAL CO2-25 BASE XS--5 ___ 05: 45PM GLUCOSE-203* LACTATE-2.5* NA+-136 K+-3.9 CL--105 TCO2-24 ___ 05: 45PM HGB-6.9* calcHCT-21 O2 SAT-97 ___ 05: 45PM freeCa-1.10* <MEDICATIONS ON ADMISSION> naproxen prn, norethindrone <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 capsule(s) by mouth twice daily Disp #*60 Capsule Refills: *0 3. Ibuprofen 600 mg PO Q6H: PRN Pain - Moderate take with food. RX *ibuprofen 600 mg 1 tablet(s) by mouth every 6 hours Disp #*50 Tablet Refills: *1 4. OxyCODONE (Immediate Release) ___ mg PO Q4H: PRN Pain - Severe Do not drink alcohol or drive while taking this medication. RX *oxycodone 5 mg ___ tablet(s) by mouth every 4 hours Disp #*30 Tablet Refills: *0 <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> Endometriosis Endometrioma Fibroids <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Dear Ms. ___, You were admitted to the gynecology service after your procedure. You have recovered well and the team believes you are ready to be discharged home. Please call Dr. ___ office with any questions or concerns. Please follow the instructions below. General instructions: * Take your medications as prescribed. * Do not drive while taking narcotics. * Take a stool softener such as colace while taking narcotics to prevent constipation. * Do not combine narcotic and sedative medications or alcohol. * Do not take more than 4000mg acetaminophen (APAP) in 24 hrs. * No strenuous activity until your post-op appointment. * Nothing in the vagina (no tampons, no douching, no sex) for 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 robotic-assisted laparoscopic bilateral ovarian cystectomy, right salpingectomy, and myomectomy. Please see the operative report for full details. Intra-operatively, she had desaturations to 69%, with heart rate in the 130s. Post-operatively, she was found to have a Hct of 21. She was given 1 unit of packed red blood cells and underwent a CT angiogram to rule out a pulmonary embolism. Immediately post-op, her pain was controlled with IV dilaudid/toradol. On post-operative day 1, her urine output was adequate so her foley was removed and she voided spontaneously. She had symptoms of lightheadedness and dizziness upon standing, and her Hct was found to be 23.6. She was given an additional 4 units of packed red blood cells during post-operative days 1 and 2, and her hematocrit at discharge was 28.8. She also experienced persistent tachycardia to the 100s-120s during her hospitalization, which was thought to be due to her anemia. She was monitored on telemetry during her hospitalization. She also experienced pleuritic chest pain and shortness of breath during her hospitalization. EKG showed normal sinus rhythm, CXR showed prominent opacity in left lower lobe, atelectasis versus pneumonitis and a tiny right pleural effusion. Her symptoms were thought to be due to pulmonary edema and pulmonary atelectasis. She was given lasix with symptomatic improvement. 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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11111129-DS-12
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Penicillins / Amoxicillin <ATTENDING> ___ <CHIEF COMPLAINT> Painful contractions <MAJOR SURGICAL OR INVASIVE PROCEDURE> Betamethasone Administration <HISTORY OF PRESENT ILLNESS> ___ y/o G6P___ ___ ___ presents to triage from the ATU with painful contractions q ___ mins. She denies VB, lof, and AFM. She denies any PTC in this pregnancy or any other pregnancy. Denies S/S of UTI. <PAST MEDICAL HISTORY> PNC: 1-Dating ___ ___ by 11+3 wk u/s ___ ___ at term, no complications ___ at term secondary to ___ ___ repeat CD at term ___ repeat CD at term 6-current GYNHx: LMP ? PMH: asthma migraine HA SurgHx: C/S x 3 <SOCIAL HISTORY> ___ <FAMILY HISTORY> non-contributory <PHYSICAL EXAM> GEN: NAD Temp: 98 po BP: 126/85 HR: 76 RR: 18 Heart: RRR S1S2 no murmur Lungs: CTA B -CVAT B Abd: gravid, soft, nontender Ext: - edema B contractions: ctx q ___ mins and painful SVE: closed/long/soft/right SSE: ffn sent <PERTINENT RESULTS> IMAGING: ___ Ultrasound: IMPRESSION: Extremely thin lower uterine segment without evidence of uterine rupture at this time. The findings were discussed with Dr. ___ at the time of the exam. LABS: ___ 03: 13PM ___ PTT-27.5 ___ ___ 03: 13PM ___ ___ 11: 01AM OTHER BODY FLUID FETALFN-NEG ___ 11: 00AM WBC-14.6* RBC-3.59* HGB-11.0* HCT-32.2* MCV-90 MCH-30.6 MCHC-34.2 RDW-13.5 ___ 11: 00AM NEUTS-79.3* LYMPHS-15.1* MONOS-3.1 EOS-2.3 BASOS-0.2 ___ 10: 59AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 LEUK-NEG MICRO: ___ GC/Chlamydia negative ___ BV culture negative <MEDICATIONS ON ADMISSION> Prenatal vitamins <DISCHARGE MEDICATIONS> Prenatal vitamins <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> Preterm Contractions 33 weeks pregnant <DISCHARGE CONDITION> Stable <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Modified bedrest Avoid stenuous activity Drink plenty of fluids Avoid being on feet for long periods of time Call if increasing abd pain, ctxs, bleeding, dec fetal movement or any other concerns.
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Ms. ___ is a ___ ___ with a history of three prior cesarean sections who presented to OB triage from the ATU with painful contractions every ___ mins. Her cervix was found to be closed. Fetal fibronectin was negative. Ultrasound revealed a thin lower uterine segment with no evidence of uterine rupture. The patient was given Nifedipine was complete resolution of her contractions. She was also given Betamethasone. Fetal testing was reassuring. She remained an inpatient until Betametasone complete. Her Nifedipine was discontinued. She had no further painful contractions during this admission. She was discharged home on HD#3 in stable condition.
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11113436-DS-4
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> adhesive tape <ATTENDING> ___ <CHIEF COMPLAINT> Stage IIB Sqamous Cell Carcinoma of the cervix <MAJOR SURGICAL OR INVASIVE PROCEDURE> Tandem and ovoid insertion Brachytherapy Tandem and ovoid removal <HISTORY OF PRESENT ILLNESS> Ms. ___ is a ___ female who had menopause in ___. She had menses-like bleeding with clots in ___, which progressed to daily vaginal bleeding. Examination by Dr. ___ on ___ revealed a large irregular firm tumor replacing the entire cervix and extending into the vaginal fornices, but not down the vaginal sidewalls. There was bilateral parametrial involvement, but not out to the pelvic sidewalls. Biopsy showed moderately to poorly differentiated squamous cell carcinoma. PET-CT on ___ showed an FDG-avid cervix, 1.5 cm right pelvic sidewall lymph node that was not FDG-avid, and a mildly avid small portacaval lymph node above the level of the renal arteries that was unlikely to be involved. There were additional subcentimeter periportal and retroperitoneal lymph nodes that were negative. Pelvic MRI on ___ demonstrated an irregular mass-like enlargement of the cervix, greater on the right, with no rectal or bladder involvement. There was bilateral parametrial invasion and a 2.5 cm prominent right iliac lymph node that was concerning for tumor involvement despite the lack of FDG uptake on the prior PET-CT. From ___ to ___, she received external beam radiation therapy to the pelvic lymph nodes to 45 Gy to the pelvis, 54 Gy to the bilateral parametria, and 63 Gy to the concerning right iliac lymph node. During the treatment, she developed diarrhea, for which she was on a low-residue diet, Imodium and Metamucil, dysuria and urinary frequency, treated with Pyridium, moderate fatigue, and moderate erythema within the treatment portal. She also had concurrent weekly cisplatin. She now returns in followup to ___ to discuss the brachytherapy portion of her treatment. Currently, Ms. ___ has been doing very well since finishing external beam radiation therapy. Although it is only eight days since she finished, she says that her diarrhea is resolved and she no longer follows the low-residue diet, or takes Metamucil or Imodium. She has one normal bowel movement a day. She no longer has dysuria and has not been taking the Pyridium anymore. She continues to have some urinary frequency and urgency, but is better. She has nocturia x 2. She denies any rectal bleeding, constipation, hematuria or urinary incontinence. She denies any abdominal or pelvic pain, vaginal bleeding or discharge, or lower extremity edema. She does have cramping of her left toes occasionally, but denies any focal numbness or paresthesias. She has had a very tough week and has a lot of anxiety and sadness as her best friend died of ovarian cancer five days ago. REVIEW OF SYSTEMS: As per history of present illness. The patient also denies any fevers, chills, headache, dizziness, nausea, vomiting, vision changes, hearing changes, chest pain, palpitations, cough, shortness of breath. All other systems are negative. <PAST MEDICAL HISTORY> <PAST MEDICAL HISTORY> - Left adrenal pheochromocytoma, s/p laparscopic resection - Hypertension - Diabetes type 2 Past Surgical History: - Laparoscopic adrenal resection - Mitral valve replacement - C-section x4 OB/GYN: - G5P5 (C-section x4). Menopause at 54. No hormone therapy or oral contracetives. Not sexually active for ___ years. <SOCIAL HISTORY> ___ <FAMILY HISTORY> noncontributory <PHYSICAL EXAM> On day of discharge: Afebrile, vitals stable No acute distress, resting comfortably CV: regular rate and rhythm. mechanical S1 Pulm: clear to auscultation bilaterally Abd: soft, appropriately tender, nondistended ___: nontender, nonedematous Gyn: Pad in place with minimal spotting <PERTINENT RESULTS> ___ 11: 10AM BLOOD WBC-7.1 RBC-3.38* Hgb-10.1* Hct-30.4* MCV-90 MCH-29.9 MCHC-33.2 RDW-18.2* RDWSD-59.0* Plt ___ ___ 07: 20AM BLOOD WBC-6.3 RBC-3.07* Hgb-9.3* Hct-28.3* MCV-92 MCH-30.3 MCHC-32.9 RDW-18.8* RDWSD-62.1* Plt ___ ___ 12: 53PM BLOOD WBC-6.1 RBC-2.88* Hgb-8.5* Hct-26.5* MCV-92 MCH-29.5 MCHC-32.1 RDW-18.8* RDWSD-62.9* Plt ___ ___ 10: 55AM BLOOD WBC-6.4# RBC-2.92* Hgb-8.7* Hct-26.8* MCV-92 MCH-29.8 MCHC-32.5 RDW-19.2* RDWSD-63.3* Plt ___ ___ 08: 00AM BLOOD WBC-4.2 RBC-3.02* Hgb-9.1* Hct-27.4* MCV-91 MCH-30.1 MCHC-33.2 RDW-19.4* RDWSD-62.2* Plt ___ ___ 11: 10AM BLOOD ___ ___ 07: 20AM BLOOD ___ ___ 12: 53PM BLOOD ___ ___ 10: 55AM BLOOD ___ ___ 08: 00AM BLOOD ___ PTT-42.7* ___ ___ 11: 10AM BLOOD Glucose-132* UreaN-9 Creat-0.8 Na-134 K-3.8 Cl-101 HCO3-24 AnGap-13 ___ 07: 20AM BLOOD Glucose-115* UreaN-7 Creat-0.8 Na-137 K-4.2 Cl-105 HCO3-27 AnGap-9 ___ 12: 53PM BLOOD Glucose-114* UreaN-11 Creat-0.9 Na-133 K-3.7 Cl-100 HCO3-26 AnGap-11 ___ 10: 55AM BLOOD Glucose-116* UreaN-12 Creat-0.9 Na-135 K-4.2 Cl-102 HCO3-26 AnGap-11 ___ 11: 10AM BLOOD Calcium-9.2 Phos-3.2 Mg-1.5* ___ 07: 20AM BLOOD Calcium-8.9 Phos-2.9 Mg-1.5* ___ 12: 53PM BLOOD Calcium-8.6 Phos-2.6* Mg-1.5* ___ 10: 55AM BLOOD Calcium-8.6 Phos-2.6* Mg-1.5* <MEDICATIONS ON ADMISSION> Fenofibrate Glyburide Lisinopril Lorazepam Metformin Phenazopyridine Pravastatin Compazine Sotalol Flomax Warfarin Aspiring Vit D3, Vit B12, fish oil <DISCHARGE MEDICATIONS> 1. Acetaminophen ___ mg PO Q4H: PRN pain Do not take more than 4,000 mg in 24 hours RX *acetaminophen 500 mg ___ tablet(s) by mouth q6h prn Disp #*40 Tablet Refills: *0 2. Aspirin 81 mg PO DAILY 3. Lisinopril 10 mg PO DAILY 4. OxycoDONE (Immediate Release) 5 mg PO Q6H: PRN pain Do not drink alcohol or drive while taking medication. RX *oxycodone 5 mg ___ tablet(s) by mouth q4h prn Disp #*40 Tablet Refills: *0 5. Pravastatin 40 mg PO DAILY 6. Sotalol 80 mg PO BID 7. Docusate Sodium 100 mg PO BID constipation Take while using pain medication. RX *docusate sodium 100 mg 1 tablet(s) by mouth twice a day Disp #*30 Tablet Refills: *0 <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> Cervical cancer <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Dear Ms. ___, You were admitted to the gynecologic oncology service for brachytherapy. You have recovered well after your treatment, and the team feels that you are safe to be discharged home. * You may notice some vaginal discharge, which is normal. You will be instructed to douche with warm water twice a day until your follow-up visit. * After your implant has been removed, it is normal to experience mild pelvic discomfort, and some irritation of your vagina. You may also experience some discomfort when you urinate or move your bowels. Please be sure to discuss any changes in your urinary or bowel patterns with your nurse. * Your activities depend on how you feel. It is important to balance your activities at ___ with frequent rest periods, particularly during the first week. * Eating a balanced diet and drinking an adequate amount of fluids will help ___ to heal and regain your strength. Please follow these instructions: * Tap water douches ___ times per day (morning and evening). * You may eat a regular diet. * Clean your skin after you urinate or move your bowels (use ___ bottle). * Refrain from sexual intercourse until your follow-up visit. To reach medical records to get the records from this hospitalization sent to your doctor at home, call ___.
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Ms. ___ was admitted to the gynecologic oncology service for vaginal brachytherapy. She underwent placement of an interstitial implant on ___. Please see operative report for full details. She received treatments from ___ until ___ for a total of 6 sessions. She was maintained on bedrest with head of bed < 30 degrees, a clear diet, and loperamide throughout this time. Her pain was controlled with a dilaudid PCA and oral acetaminophen. After removal of the implant on hospital day 4, her diet was advanced without difficulty. Her Foley catheter was removed and she voided spontaneously. She was transitioned to oral oxycodone and acetaminophen for her pain. By hospital day 4, she was tolerating a regular diet, voiding spontaneously, ambulating independently, and pain was controlled on oral medications. She was then discharged home in stable condition with outpatient follow-up scheduled.
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11117183-DS-19
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___ <CHIEF COMPLAINT> headache <MAJOR SURGICAL OR INVASIVE PROCEDURE> none <HISTORY OF PRESENT ILLNESS> ___ G with suspected cHTN and hx of pre-E without severe features in her prior pregnancy who presents with HA, leg swelling/cramping and some DOE while walking outside. She also reports frequent HA in this pregnancy, every other day. This HA feels the same as her prior HAs which are usually repsonsive to tylenol. Initial triage vitals: 98.4 108 136/94 18 100% with rpt bps in the normal range 110-120/60-80. EKG and BNP normal in ED. Received 1g acetaminophen with significant improvement in HA and was transfered to OB Triage. On presentation to Ob triage she reports heartburn, which is epigastric and occurred after lying flat after eating a meal. Otherwise no visual changes, RUQ/epigastric pain, CP/SOB. <PAST MEDICAL HISTORY> PNC: 1)Dating: EDC ___ by 12wk u/s at ___ 2)Routine testing: O+, antibody neg, RPR NR, rubella immune, HbsAg NR, HIV neg 3)genetics: LR QUAD 4)FFS: nl except L EIF 5)Issues with this pregnancy: 1. UTI dx at ___ ED ___ -> ucx from IOB 2. hx pre-E, nl baseline labs at 15 weeks Prior BP in this pregnancy: 13w5d 118/90 19w5d 100/70 28w5d 132/90, 143/96 3. living in shelter -> following w/sw for resources OB Hx: G1: LTCS for NRFHR at 36+4 IOL pre-E with infant born with unknown gastroschisis G2: current Gyn Hx: hx chlamydia PMH: denies PSH: tonsillectomy ___, LTCSx1 <SOCIAL HISTORY> ___ <FAMILY HISTORY> non-contributory <PHYSICAL EXAM> At admission: VS: T 98.7 BP 127/75 HR 115 RR 16 CV: rrr w/o m/g/r Chest: CTA B Abd: gravid, soft, nontender Back: R sided CVAT Ext: -edema B SVE: deferred On day of discharge: AFVSS Gen: NAD Abd: soft, nontender Back: mild R side CVA tenderness Ext: no edema or ttp <PERTINENT RESULTS> ___ 01: 00PM URINE RBC-1 WBC-88* BACTERIA-FEW YEAST-NONE EPI-2 TRANS EPI-<1 ___ 01: 00PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.5 LEUK-LG ___ 01: 00PM WBC-5.5 RBC-3.42* HGB-9.6* HCT-29.6* MCV-86 MCH-28.0 MCHC-32.4 RDW-16.3* ___ 01: 00PM NEUTS-64.9 ___ MONOS-7.2 EOS-0.8 BASOS-0.4 ___ 01: 00PM PLT COUNT-213 ___ 01: 00PM ALBUMIN-3.5 URIC ACID-4.5 ___ 01: 00PM URINE HOURS-RANDOM CREAT-65 TOT PROT-10 PROT/CREA-0.2 ___ 01: 00PM proBNP-<5 ___ 01: 00PM LIPASE-18 ___ 01: 00PM ALT(SGPT)-14 AST(SGOT)-25 ALK PHOS-78 TOT BILI-0.1 ___ 01: 00PM GLUCOSE-76 UREA N-6 CREAT-0.5 SODIUM-137 POTASSIUM-4.0 CHLORIDE-105 TOTAL CO2-23 ANION GAP-13 ___ Urine Culture - proteus mirabilis, pan sensitive <MEDICATIONS ON ADMISSION> prenatal vitamins <DISCHARGE MEDICATIONS> 1. Prenatal Vitamins 1 TAB PO DAILY 2. Terconazole 0.4% Vag. Cream 1 Appl VG DAILY Duration: 7 Days RX *terconazole 0.4 % insert one application into the vagina daily Disp #*1 Package Refills: *0 3. Ampicillin 500 mg PO Q6H Duration: 10 Days RX *ampicillin 500 mg 1 capsule(s) by mouth every 6 hours Disp #*40 Capsule Refills: *0 <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> pregnancy at 29 weeks pyelonephritis yeast 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 antepartum service for treatment of a kidney infection. You received two doses of IV antibiotics for this and will continue to take oral antibiotics at home. We also did a test for gestational diabetes which was normal and you were started on treatment for a yeast infection. We continued to monitor the baby while you were in the hospital and you are now stable for discharge.
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Ms. ___ was admitted to the antepartum service at 29w1d for treatment of pyelonephritis after presenting to the emergency department with headache and shortness of breath in the setting of a recent untreated urine culture positive for proteus mirabilis. She was given IV fluids and started on IV ceftriaxone. She was afebrile at admission and remained afebrile throughout her stay. Her CBC showed no leukocytosis. On admission she had + CVA tenderness which was resolving at the time of discharge. In addition, her blood pressure in OB triage was 136/94. She had a history of blood pressures >140/80 before 20wks gestation so there was indication that she may have chronic hypertension versus evolving pre-eclampsia. Her pre-eclampsia labs were normal and she had a urine P/C ratio of 0.2. A 24hr urine protein was deferred at this time as her current bacturia would confound the results. She remained normotensive and asymptomatic throughout her hospitalization. She reported vaginal itching and discharge consistent with a yeast infection on HD#3 and was started on teraconazole for treatment. In addition, she had a GLT which was normal. She received routine fetal monitoring throughout her stay which was reassuring. She was transitioned to PO antibiotics and was discharged in stable condition with outpatient follow-up.
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11117183-DS-20
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___ <CHIEF COMPLAINT> headache <MAJOR SURGICAL OR INVASIVE PROCEDURE> none <HISTORY OF PRESENT ILLNESS> ___ yo G2P1 at ___ presented with elevated HA and persistent HA unrelieved by Tylenol. Patient reports that she felt well when she initially woke up but then developed a left sided HA, worse behind her eye for which she took Tylenol. HA initially improved but did not go away and then worsened. She took her BP at home and it measured 156/105 and 142/102. She called the office and was advised to present to OB triage for evaluation. In triage, patient continued to endorse "worst headache ever" located on the left side and greated behind her eye left for which she received 2 Tabs fioricet. She denies visual changes and abdominal pain. BP's were initially mild range but she then was noted to have severe range BP's to 160/109 and 164/114 and she was given labetalol 20 mg IV. However, shortly after medication was administered, it was noted that the IV had infiltrated and it unclear how much of the medication was actually given intravenously. BP then noted to be back in mild range and patient was admitted to L&D for close BP monitoring and 24 hour urine collection. <PAST MEDICAL HISTORY> PNC: Dating: EDC ___ by ___ tri u/s Labs: O pos/Ab neg/HBsAg neg/RPR NR/RI/HIV neg/GBS unknown Screens: Low risk Quad, FFS w/ EIF but otherwise wnl, declined further screening Issues: *) h/o preeclampsia in first pregnancy: Delivered at 36 weeks. Basline labs wnl. *) h/o c/s for preeclampsia and NRFHT: Desires elective repeat. *) H/o infant born with unknown gastroschisis: s/p MFM consult. FFS normal. *) Social: Patient lives in a shelter and was seen in OB triage this pregnancy for DV by FOB. Patient now reports feeling safe, FOB is involved. *) h/o pyelonephritis w/ admission ___: U Cx w/ pan sensitive proteus mirabilis s/p treatment followed by negative TOC. POBH: G2P1 ___ - LTCS for preeclampsia and NRFHT at 36w4d. Fetal gastroschisis diagnosed at time of delivery PGynH: h/o chlamydia PMH: Denies PSH: tonsillectomy ___, LTCS <SOCIAL HISTORY> ___ <FAMILY HISTORY> non-contributory <PHYSICAL EXAM> (on admission) VS - T 98.3, BP 145/97, ___, 164/114, 153/92, 150/98 Gen - Nontoxic, NAD CV - RRR Resp - CTAB Abd - soft, gravid, nontender Ext - Trace edema, 3+ DTR's and 1 beat clonus bilaterally FHT - 140, moderate variability, + accels, no decels Toco - Flat SVE - deferred <PERTINENT RESULTS> ___ WBC-5.2 RBC-3.76 Hgb-9.6 Hct-29.8 MCV-79 Plt-178 ___ Creat-0.7 ALT-13 UricAcd-4.5 ___ URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG ___ URINE Hours-RANDOM Creat-46 TotProt-6 Prot/Cr-0.1 ___ URINE pH-6 Hours-24 Volume-3500 Creat-14 TotProt-<6 ___ URINE 24Creat-490 R/O GROUP B BETA STREP (Final ___: POSITIVE FOR GROUP B BETA STREP <MEDICATIONS ON ADMISSION> PNV <DISCHARGE MEDICATIONS> 1. Acetaminophen ___ mg PO Q6H: PRN headache RX *acetaminophen 500 mg ___ tablet(s) by mouth every 6 hours Disp #*30 Tablet Refills: *3 2. Ferrous Sulfate 325 mg PO DAILY RX *ferrous sulfate 325 mg (65 mg iron) 1 tablet(s) by mouth daily Disp #*30 Tablet Refills: *2 3. Labetalol 200 mg PO BID RX *labetalol 200 mg 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills: *0 4. Metoclopramide 10 mg PO ONCE Duration: 1 Dose RX *metoclopramide HCl 10 mg 1 tab by mouth every 6hrs Disp #*20 Tablet Refills: *0 5. Prenatal Vitamins 1 TAB PO DAILY <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> pregnancy at 35w4d gestational hypertension <DISCHARGE CONDITION> stable <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> You were admitted to the antepartum floor for observation due to gestational hypertension. You were started on a low dose of medicaion for your blood pressures. It is important that you continue taking this. You had no evidence of preeclampsia. Fetal testing was reassuring. Please keep all of your scheduled appointments.
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___ yo G2P1 admitted at 35w2d with a headache and elevated blood pressures. On arrival, her blood pressures were elevated and reached severe range. She was given one dose of IV Labetolol, however, her IV had infiltrated and she may have not actually gotten the medication. Regardless, her blood pressures improved significantly and her headache resolved with Fioricet. Fetal testing was reassuring. Preeclampsia labs were normal. She was admitted to antepartum for observation and a 24 hour urine collection. She was started on po Labetolol 200mg bid, and her blood pressures remained in the normal to mildly elevated range. Her 24 hour urine was negative and she continued to feel well. Ultrasound in the ___ was reassuring with a BPP ___ and low-normal AFI (6). Given she had no evidence of preeclampsia, she was discharged home and will have close outpatient followup. She was scheduled for a repeat BPP in the ___ on ___, ___.
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11117183-DS-21
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___ <CHIEF COMPLAINT> headache <MAJOR SURGICAL OR INVASIVE PROCEDURE> none <HISTORY OF PRESENT ILLNESS> ___ G6P2 at 32+3 with cHTN, seen today for BP check with BPs 140's over 90-100's. Also reports ___ frontal headache that started around 0500 today. Has been having headaches off/on throughout this entire pregnancy. Last couple weeks they seem more frequent and more intense. Hasn't tried any medications today for pain. Denies visual changes. Does report RUQ pain that has been present for "months". Denies CTX, VB or LOF. This AM less FM, but since having some food normal FM. <PAST MEDICAL HISTORY> PNC: -___: ___ -Labs: O+/Ab-/HBsAg-/RPRNR/RI/HIV-/GBS+ (___) -Screening: LR ERA, normal ___ -FFS: EIF, otherwise WNL, posterior placenta -GLT: 108 OBHx: -TAB x2 -SAB x1 -pLTCS, 36+4, NRFHT, preeclampsia, fetal gastroschisis -rLTCS, 36+3, preeclampsia -current GynHx: trichamonas in ___ and ___, neg TOC since PMH: anxiety PSH: C/X x2, tonsillectomy <SOCIAL HISTORY> N/A <PHYSICAL EXAM> Alert, oriented Breathing comfortably on room air Abdomen soft, non tender Extremities non tender <PERTINENT RESULTS> ___ 11: 22AM BLOOD WBC-5.0 RBC-3.45* Hgb-9.3* Hct-29.1* MCV-84 MCH-27.0 MCHC-32.0 RDW-13.1 RDWSD-40.0 Plt ___ ___ 11: 22AM BLOOD Creat-0.6 ___ 11: 22AM BLOOD ALT-10 AST-16 ___ 11: 22AM BLOOD UricAcd-4.1 ___ 11: 22AM URINE Color-Yellow Appear-Hazy* Sp ___ ___ 11: 22AM URINE Blood-NEG Nitrite-NEG Protein-TR* Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.5 Leuks-NEG ___ 11: 22AM URINE RBC-0 WBC-0 Bacteri-FEW* Yeast-NONE Epi-7 ___ 11: 02AM URINE pH-6 Hours-24 Volume-2925 Creat-60 TotProt-10 Prot/Cr-0.2 ___ 11: 22AM URINE Hours-RANDOM Creat-88 TotProt-11 Prot/Cr-0.1 ___ 11: 02AM URINE 24Creat-1755 24Prot-293 <MEDICATIONS ON ADMISSION> ___ 81mg, Zantac PRN <DISCHARGE MEDICATIONS> 1. Acetaminophen-Caff-Butalbital ___ TAB PO Q8H: PRN Headache RX *butalbital-acetaminophen-caff 50 mg-325 mg-40 mg ___ tablet(s) by mouth once per day Disp #*10 Tablet Refills: *0 2. Acetaminophen ___ mg PO Q6H: PRN Pain 3. Aspirin 81 mg PO DAILY 4. Prenatal Vitamins 1 TAB PO DAILY <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> chronic hypertension <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Dear. Ms. ___, You were admitted to the hospital with elevated blood pressures. Your blood pressures were monitored overnight and remained normal. Your urine collection indicated that you do not have preeclampsia. Your headache resolved with fioricet. We think it is now safe for you to go home. Please follow the instructions below: - Attend all appointments with your obstetrician and all fetal scans - Monitor for the following danger signs: - headache that is not responsive to medication - abdominal pain - increased swelling in your legs - vision changes - Worsening, painful or regular contractions - Vaginal bleeding - Leakage of water or concern that your water broke - Nausea/vomiting - Fever, chills - Decreased fetal movement - Other concerns
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Ms. ___ is a ___ G6P2 with cHTN, who was admitted to the hospital with a headache for evaluation for pre-eclampsia. Her PEC labs were normal on admission, with a P/C 0.1. Her HA resolved with fiorecet and Benadryl. Her 24 hour urine protein resulted as 293. Her blood pressures during admission were normal. She had a fetal ultrasound that showed a fetus weighing 2399 grams, 72%ile. BPP ___ with reassuring and reactive NSTs during admission. She was discharged home on ___ in stable condition with precautions and instructions for follow up.
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11117183-DS-22
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___ <CHIEF COMPLAINT> chest pressure, SOB <MAJOR SURGICAL OR INVASIVE PROCEDURE> none <HISTORY OF PRESENT ILLNESS> ___ G6P___ at 35w3d presents to triage c/o worsening chest discomfort and difficulty sleeping due to shortness of breath. Feels a heaviness in her chest all the time, but it gets worse with lying down. States she's had these symptoms for "awhile" but they're getting worse. Pt states she wakes up out of sleep gasping and finds it very distressing. no hx sleep apnea. feels like this is different than her anxiety symptoms. She denies any headaches. reports sensitivity to light in sun. reports she's staying hydrated. no n/v/d. feels occasional non-painful tightenings. no LOF, VB. +FM <PAST MEDICAL HISTORY> PNC: - ___: ___ by 8wk US - Labs: O+/Ab-/HBsAg-/RPRNR/RI/HIV-/GBS+ (___) - Screening: LR ERA, normal ___ - FFS: EIF, otherwise WNL, posterior placenta - GLT: 108 ISSUES *) hx prior c/s x 2, desires TOLAC *) hx anxiety: no meds. tried Zoloft in ?___ but states she had worsening nighttime anxiety *) cHTN - no meds - BPs in office 130-140s/80s with exception of isolated 149/101 on ___ which prompted antepartum admission - admitted to antepartum ___ with elev BP and HA, improved with Fioricet and Benadryl. 24hr urine neg. - 24hr urine: ___ -> ___ - ___: 2399g(72%) <SOCIAL HISTORY> ___ <FAMILY HISTORY> non contributory <PHYSICAL EXAM> Gen: appears comfortable, lying on her side VS: 98.4, 113/74, 106, 18, O2 100% Resp: no evidence of resp distress Abd: soft, gravid, NT Ext: no calf tenderness SVE: deferred -> pt prefers to happen later <PERTINENT RESULTS> ___ 01: 41PM BLOOD WBC-5.0 RBC-3.62* Hgb-9.2* Hct-29.3* MCV-81* MCH-25.4* MCHC-31.4* RDW-13.6 RDWSD-39.8 Plt ___ ___ 01: 41PM BLOOD Creat-0.5 ___ 01: 41PM BLOOD ALT-9 AST-17 ___ 01: 41PM BLOOD UricAcd-3.9 <MEDICATIONS ON ADMISSION> ___ 81mg, Zantac PRN <DISCHARGE MEDICATIONS> 1. Acetaminophen 650 mg PO Q6H: PRN Pain 2. Prenatal Vitamins 1 TAB PO DAILY <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> Chronic Hypertension <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Dear. Ms. ___, You were admitted to the hospital with elevated blood pressures. Your blood pressures were monitored overnight and remained normal to moderately elevated. Your urine collection indicated that you do not have preeclampsia. We think it is now safe for you to go home. Please follow the instructions below: - Attend all appointments with your obstetrician and all fetal scans Monitor for the following danger signs: - headache that is not responsive to medication - abdominal pain - increased swelling in your legs - vision changes - Worsening, painful or regular contractions - Vaginal bleeding - Leakage of water or concern that your water broke - Nausea/vomiting - Fever, chills - Decreased fetal movement - Other concerns
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Ms. ___ is a ___ G6P___ with cHTN who was admitted for worsening HTN. She presented with shortness of breath and chest pressure. She had a normal oxygen saturation and a EKG that showed sinus tachycardia. She was admitted for observation. She had normal PIH labs and a negative 24H urine. She did have one non sustained severe range BP in triage, but for the remainder of her hospital stay, she had normal to mild range blood pressures (max 140's/90's). She was discharged home in stable condition with instructions for follow up.
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11119056-DS-7
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___ <CHIEF COMPLAINT> follow up for low platelets and elevated LFTs <MAJOR SURGICAL OR INVASIVE PROCEDURE> none <HISTORY OF PRESENT ILLNESS> This is a ___ yo G4P1 who presents at 36w0d for follow up of lab abnormalities. Low platelets were noted on ___. Has a hx of gestational thrombocytopenia in her last pregnancy. ___ 88* ___ 81* ___ 94* ___ 116* ___ 143* ___ 211 ___ 215 ROS: Denies headache, visual changes, RUQ or epigastric pain. Denies fever, chills, other abdominal pain, abdominal trauma, dysuria, vaginal discharge. Denies CTX, vaginal bleeding, DFM, LOF. <PAST MEDICAL HISTORY> PNC: ___ ___ by ___ Labs: A POS/ Abs neg/ RI/ RPRNR/ HIV-/ HBsAg-/GBS neg Glucose screening: normal Genetics screening: Elevated Trisomy 21 risk on Quad; LR NIPT Issues: - thrombocytopenia (see trend above) PObHx: No history of PEC, gHTN. - 40 week SVD 8#9oz male; gestational thrombocytopenia, resolved post partum, no - tab x 1 - sab x 1 PGynHx: remote hx of chlamydia, negative in this pregnancy, denies other STI, fibroids, cysts PMHx: denies PSHx: breast lumpectomy- benign <SOCIAL HISTORY> ___ <FAMILY HISTORY> non-contributory <PHYSICAL EXAM> (on admission) Afebrile, HR 73, BP 105/67, RR 12 General: NAD Cardiac: RRR Abdomen: soft, no fundal tenderness, no epigastric tenderness, no RUQ tenderness, soft, non distended Ext: no erythema, no edema SVE: deferred NST: 130/ mod var/ + accels/ no decels TOCO: flat BPP: VTX, ___, AFI: 18 <PERTINENT RESULTS> ___ WBC-5.3 RBC-3.51 Hgb-11.3 Hct-32.6 MCV-93 Plt-88 ___ WBC-5.5 RBC-3.33 Hgb-10.7 Hct-31.2 MCV-94 Plt-83 ___ WBC-5.1 RBC-3.39 Hgb-11.1 Hct-31.4 MCV-93 Plt-86 ___ WBC-5.1 RBC-3.33 Hgb-10.7 Hct-31.2 MCV-94 Plt-78 ___ WBC-5.4 RBC-3.29 Hgb-10.3 Hct-30.8 MCV-94 Plt-81 ___ ___ PTT-27.5 ___ ___ Creat-0.5 ALT-113 AST-96 UricAcd-4.6 ___ Creat-0.4 ALT-105 AST-84 LD(LDH)-214 Hapto-61 ___ Creat-0.6 ALT-108 AST-87 ___ ALT-110 AST-86 ___ Creat-0.5 ALT-107 AST-79 ___ IgM HAV-NEGATIVE HCV Ab-NEGATIVE ___ URINE Blood-NEG Nitrite-NEG Protein-TR Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG ___ URINE RBC-0 WBC-0 Bacteri-NONE Yeast-NONE Epi-9 ___ URINE Hours-RANDOM Creat-100 TotProt-7 Prot/Cr-0.1 ___ URINE pH-7 Hours-24 Volume-900 Creat-115 TotProt-18 Prot/Cr-0.2 ___ URINE 24Creat-1035 24Prot-162 ___ VIRUS VCA-IgG AB (Final ___: POSITIVE BY EIA. ___ VIRUS EBNA IgG AB (Final ___: POSITIVE BY EIA. ___ VIRUS VCA-IgM AB (Final ___: NEGATIVE <1: 10 BY IFA <MEDICATIONS ON ADMISSION> prenatal vitamins <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> IUP 36wks stable transaminitis and known gestational thrombocytopenia <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> routine
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___ yo G4P1 admitted at 36w0d for further surveillance of her elevated liver enzymes and low platelets. MFM was consulted and followed her. She remained normotensive throughout this admission and had a negative 24 hour urine collection. Fetal testing was reassuring. Although her low platelet count is thought to be gestational thrombocytopenia, the etiology of her mild transaminitis is unclear. Her platelet count and LFTs remained stable. Hepatitis and viral studies were negative. Given all her labs were stable and she had no evidence of preeclampsia, she was discharged home in stable condition on ___ and will have close outpatient followup.
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11121483-DS-17
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> mold / mildew / strawberry / Norvasc / Levaquin <ATTENDING> ___ ___ Complaint: Ovarian/peritoneal cancer s/p neoadjuvant chemotherapy <MAJOR SURGICAL OR INVASIVE PROCEDURE> robotic assisted total laparascopic hysterectomy, bilateral salpingo-oophrectomy, omentectomy, cystoscopy <HISTORY OF PRESENT ILLNESS> Ms. ___ is a ___ yo female who presented to clinic on ___ for followup and interval assessment of her presumed primary peritoneal high-grade serous carcinoma status post three cycles of carboplatin and Taxol chemotherapy. She states that she has tolerated chemotherapy reasonably well and she states that her last cycle was on ___ with her fourth cycle tentatively scheduled for ___. She also has an abdominal aortic aneurysm and right external iliac artery aneurysm is being followed by Dr. ___ (s/p repair on ___. She states that the bloating has decreased as well as the pain. Per conversation with Dr. ___ appears that her pretreatment CA-125 was 373 (___) and this decreased to 28.8 on ___ prior to her third cycle. The patient states that she has had no vaginal bleeding, discharge or significant change in her bowel function other than some constipation. She reports very minimal nausea and vomiting only x 1 following cycle #1 of chemotherapy. <PAST MEDICAL HISTORY> PMH: 1. Asthma, stress induced. She also gets flare-ups associated with bronchitis and pneumonia. She last used steroids about two to three months ago and gets these bouts of bronchitis and pneumonia up to one to two times a year. 2. Diabetes, on no medication. 3. Hypertension. 4. Low back pain. 5. History of Lyme disease. 6. History of spontaneous rupture of the spleen. 7. Skin cancer (squamous cell carcinoma) status post Mohs surgery. PSH: AAA repair on ___, splenectomy ___, MOHs, cosmetic eye surgery s/p trauma, lap chole ___ years ago, tonsillectomy, adenoidectomy OB/GYN HISTORY: Menopause ___ years ago. She denies postmenopausal bleeding or hormone replacement therapy. She did experience some hot flashes in the past, but none currently. She is gravida 0 and states that she was never able to conceive. She did not undergo any sort of formal infertility treatments, but never took contraception except for a very brief time, which she states was not agreeable with her. She has had normal regular Pap smears in the past and she denies history of STIs. <SOCIAL HISTORY> ___ <FAMILY HISTORY> Negative for any breast cancer, ovarian cancer or uterine cancer. She believes that her mother may have had colon cancer, although this was not formally diagnosed. Her mother also had ___. Her father is deceased at age ___ from a heart attack as well as her brother at age ___. <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> ___ 07: 03PM URINE HOURS-RANDOM CREAT-79 SODIUM-47 ___ 07: 00PM GLUCOSE-168* UREA N-24* CREAT-1.4* SODIUM-134 POTASSIUM-4.7 CHLORIDE-97 TOTAL CO2-27 ANION GAP-15 ___ 07: 00PM WBC-15.6* RBC-2.79* HGB-7.9* HCT-24.4* MCV-88 MCH-28.3 MCHC-32.4 RDW-17.6* RDWSD-56.0* ___ 07: 00PM PLT COUNT-530* ___ 07: 45AM GLUCOSE-134* UREA N-26* CREAT-1.7* SODIUM-135 POTASSIUM-4.4 CHLORIDE-95* TOTAL CO2-25 ANION GAP-19 ___ 07: 45AM CALCIUM-9.8 PHOSPHATE-4.6* MAGNESIUM-2.4 ___ 07: 45AM WBC-15.1* RBC-3.24* HGB-9.0* HCT-28.1* MCV-87 MCH-27.8 MCHC-32.0 RDW-17.5* RDWSD-55.6* ___ 07: 45AM NEUTS-72.8* LYMPHS-15.3* MONOS-9.0 EOS-1.9 BASOS-0.3 IM ___ AbsNeut-10.98* AbsLymp-2.31 AbsMono-1.35* AbsEos-0.28 AbsBaso-0.05 ___ 07: 45AM PLT COUNT-623* <MEDICATIONS ON ADMISSION> nifedipine 30mg CR, atorvastatin 20mg , lisinopril 40mg, albuterol prn, symbicort 4.5/160, oxycodone 10mg q4prn, HCTZ 25mg daily, gabapentin 300mg TID, aspirin 81mg <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 100 mg 1 capsule(s) by mouth twice daily Disp #*60 Capsule Refills: *0 3. Gabapentin 300 mg PO BID RX *gabapentin 300 mg 1 capsule(s) by mouth twice daily Disp #*60 Capsule Refills: *0 4. OxyCODONE (Immediate Release) ___ mg PO Q4H: PRN Pain - Moderate Do not drink alcohol or drive. RX *oxycodone 5 mg ___ tablet(s) by mouth every 4 hours Disp #*30 Tablet Refills: *0 5. Aspirin 81 mg PO DAILY 6. Atorvastatin 20 mg PO QPM 7. Ciprofloxacin HCl 500 mg PO Q12H Duration: 3 Days 8. NIFEdipine CR 30 mg PO DAILY 9. Symbicort (budesonide-formoterol) 160-4.5 mcg/actuation inhalation DAILY <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> high grade serous carcinoma, ___ <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. . 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 robotic assisted total laparoscopic hysterectomy, bilateral salpingo-oophrectomy, omentectomy, 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/PO acetaminophen. For her solitary functional kidney, her creatinine was monitored, and was found to be 1.4 post-operatively (down from 1.7 pre-operatively). Nephrotoxic drugs were held, and her home aspirin and furosemide was given. Vascular surgery was also consulted. For her recent UTI, she was continued on her course of ciprofloxacin. For her diabetes, her blood sugars were monitored and she was placed on an insulin sliding scale. For her lower back pain, her home gabapentin was decreased to BID dosing (from TID) due to renal dysfunction, and she was also given oxycodone. For her asthma she was continued on her home medications. For her hypertension, her home lisinopril and hydrochlorothiazide were held, and her nifedipine was restarted on post-operative day #1. Her diet was advanced without difficulty and she was transitioned to oral acetaminophen/oxycodone(pain meds). On post-operative day #1, her urine output was adequate so her Foley catheter was removed and she voided spontaneously. By post-operative day 1, she was tolerating a regular diet, voiding spontaneously, ambulating independently, and pain was controlled with oral medications. She was then discharged home in stable condition with outpatient follow-up scheduled.
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11121734-DS-5
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Toradol / Zantac <ATTENDING> ___ <CHIEF COMPLAINT> contractions/pressure <MAJOR SURGICAL OR INVASIVE PROCEDURE> None <HISTORY OF PRESENT ILLNESS> ___ G4P1 @ 27+3 WGA presents to triage with ongoing pelvic pressure. Presented day prior where w/u was normal, SVE 1/long, neg fFN, UA and UCx neg. Returns today with ongoing pressure, constant. Denies regular contractions or LOF, no VB. +AFM but overall decreased this past week. <PAST MEDICAL HISTORY> PNC: -___ ___ by LMP confirmed by ___ tri ultrasound -Labs: O+/Ab-/RI/RPRNR/HbSAg-/HIV- -GC/CT- on ___ and ___ -Screening: low-risk ERA -Issues: 1. BV dx at ___ PNV, +wet prep, treated with metrogel 2. ED visit ___ around 7wks gestation for "burning pain in stomach" OBHx: -G4P1 -G1: ___, SVD, 37w, 5#4, at ___ -G2: ___, TAB -G3: ___, ectopic pregnancy, at ___, had surgery but did not require salpingectomy -G4: current GynHx: -hx CT x 2 -hx possible PID in setting of D&C and diagnosis of ectopic pregnancy -BV seen at first prenatal visit PMH: denies PSH: D&C, ? laparoscopy for ectopic, denies salpingectomy <SOCIAL HISTORY> ___ <FAMILY HISTORY> non-contributory <PHYSICAL EXAM> On admission: VS: T 98 HR 84 RR 18 130/67 Gen: appears comfortable Abd: soft, gravid, no rebound or guarding, no TTP Back: tender in paraspinal muscles with light to mod palpation. No CVAT. SVE: 1/long/post/firm (unchanged) TVUS: CL 2.7cm -> 23-25mm in CMFM TAUS: cephalic, BPP ___ FHT: 140/reactive AGA Toco: flat <PERTINENT RESULTS> ___ WBC-8.8 RBC-3.42 Hgb-11.1 Hct-31.2 MCV-91 Plt-249 ___ Neuts-69.0 ___ Monos-5.7 Eos-0.7 Baso-0.2 ___ Glucose-124 ___ ALT-12 ___ URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG ___ URINE RBC-22 WBC-6 Bacteri-FEW Yeast-NONE Epi-14 ___ OTHER BODY FLUID FetalFN-NEGATIVE <MEDICATIONS ON ADMISSION> Unisom PNV <DISCHARGE MEDICATIONS> 1. Acetaminophen 650 mg PO Q6H: PRN Pain 2. Docusate Sodium 100 mg PO BID 3. Prenatal Vitamins 1 TAB PO DAILY <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> vaginal pressure <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Ms. ___, You were admitted to the hospital for observation. You also received a course of steroids to help protect the baby in case of a preterm delivery. After observation, the team feels that it is safe for you to be discharged. 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 at 27w3d with persistent pelvic pressure and new finding of a short cervix. She was afebrile and without any evidence of infection or abruption. She had no contractions on toco and her cervix was unchanged (1/long) from one day prior. Fetal testing was reassuring. She was given a course of betamethasone for fetal lung maturity (complete ___. She remained clinically stable without any evidence of preterm labor. She was discharged home and will have close outpatient followup. . Of note, social services met with her given her history of depression, social stressors, and frequent presentations.
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11121734-DS-6
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Toradol / Zantac <ATTENDING> ___. <CHIEF COMPLAINT> abdominal pain <MAJOR SURGICAL OR INVASIVE PROCEDURE> none <HISTORY OF PRESENT ILLNESS> Ms. ___ is a ___ year old G4P1 at ___ with hx of abdominal pain (multi visits), GERD, and possible gHTN, depression and domestic violence who presents to triage after acute onset RUQ pain radiating to her back this morning. She endorses one episode of vomiting today. She denies fever, chills, diarrhea, constipation, dysuria, drug use. She denies any abdominal trauma and reports feeling safe at home. The pain she was seen for previously was more in the lower abdomen. Of note, she was admitted for observation in ___ for preterm contractions and made betamethasone complete. <PAST MEDICAL HISTORY> PNC: -___ ___ by LMP confirmed by ___ tri ultrasound -Labs: O+/Ab-/RI/RPRNR/HbSAg-/HIV- -GC/CT- on ___ and ___ -Screening: low-risk ERA -Issues: 1. BV dx at ___ PNV, +wet prep, treated with metrogel 2. ED visit ___ around 7wks gestation for "burning pain in stomach" OBHx: -G4P1 -G1: ___, SVD, 37w, 5#4, at ___ -G2: ___, TAB -G3: ___, ectopic pregnancy, at ___, had surgery but did not require salpingectomy -G4: current GynHx: -hx CT x 2 -hx possible PID in setting of D&C and diagnosis of ectopic pregnancy -BV seen at first prenatal visit PMH: denies PSH: D&C, ? laparoscopy for ectopic, denies salpingectomy <SOCIAL HISTORY> ___ <FAMILY HISTORY> non-contributory <PHYSICAL EXAM> VS: T 98.5 HR 115 BP 129/79 R 20 Gen: uncomfortable, shifting in bed but able to converse without difficulty Abd: soft, gravid, + epigastric or RUQ ttp, no fundal ttp, no rebound or guarding Back: R mod CVAT, left neg. SVE: 1/long/firm/post Toco: flat FHT 125/mod var/+accels/-decels/reactive <PERTINENT RESULTS> ___ 11: 25AM URINE HOURS-RANDOM CREAT-97 TOT PROT-11 PROT/CREA-0.1 ___ 11: 25AM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG cocaine-NEG amphetmn-NEG mthdone-NEG ___ 11: 25AM URINE COLOR-Yellow APPEAR-Clear SP ___ ___ 11: 25AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 LEUK-NEG ___ 11: 25AM URINE RBC-1 WBC-3 BACTERIA-FEW YEAST-NONE EPI-2 TRANS EPI-<1 ___ 11: 24AM CREAT-0.5 ___ 11: 24AM ALT(SGPT)-20 AST(SGOT)-24 LD(LDH)-170 TOT BILI-0.4 ___ 11: 24AM LIPASE-25 ___ 11: 24AM URIC ACID-3.4 ___ 11: 24AM WBC-10.4 RBC-3.90* HGB-12.5 HCT-35.7* MCV-92 MCH-32.1* MCHC-35.0 RDW-12.7 ___ 11: 24AM NEUTS-72.9* ___ MONOS-8.2 EOS-0.3 BASOS-0.2 ___ 11: 24AM PLT COUNT-279 ___ 11: 24AM ___ PTT-29.2 ___ ___ 11: 24AM ___ <MEDICATIONS ON ADMISSION> PNV, Unisom, Fiorocet prn headaches <DISCHARGE MEDICATIONS> 1. Prenatal Vitamins 1 TAB PO DAILY 2. Sertraline 25 mg PO DAILY RX *sertraline 25 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills: *6 3. OxycoDONE (Immediate Release) 5 mg PO ONCE Duration: 1 Dose RX *oxycodone 5 mg 1 tablet(s) by mouth every six (6) hours Disp #*12 Tablet Refills: *0 <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> right sided abdominal and back pain <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Dear Ms. ___, You were admitted to ___ after presenting with right sided abdominal and back pain. You had an ultrasound which showed swelling of right kidney. However, your lab work and urine was not suggestive of a kidney stone. Urology was consulted who thought your pain was likely musculoskeletal. Your pain has been well managed with pain medications. The team feels it's now safe for you to go home. Please call the office for: - Worsening, painful or regular contractions - Vaginal bleeding - Leakage of water or concern that your water broke - Abdominal pain - Nausea/vomiting - Fever, chills - Decreased fetal movement - Other concerns
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Ms. ___ is a ___ yo G4P1 with possible gHTN who was admitted at 31w 2d on ___ with right sided abdominal and back pain. Her WBC, creatinine and UA were normal on admission but had an ultrasound which showed severe right hydronephrosis. Urology was consulted who thought that the ultrasound finding was likely incidental and had low suspicion for stone given normal creatinine and UA. Her pain was thought to be likely musculoskeletal in origin and was managed with tylenol, heat packs and oxycodone. She had reactive daily NSTs and her BPs were normal while on the floor. She was discharged home in stable condition with outpatient follow up scheduled. , low suspicion for kidney stone and no evidence of infection.
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11121734-DS-8
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___ <CHIEF COMPLAINT> right lower quadrant pain <MAJOR SURGICAL OR INVASIVE PROCEDURE> dilation and curettage <HISTORY OF PRESENT ILLNESS> ___ yo G7P___ woman with a history of right nephrolithiasis s/p TAB on ___ who presents with RLQ pain. After her manual vacuum aspiration (MVA) on ___ she was started on the patch for contraception. She had no bleeding after the procedure, but had persistent n/v for 3 weeks and therefore discontinued the patch. She then began to have vaginal bleeding the middle of ___ that was much heavier than normal with passage of large clots. The bleeding stopped after 2 weeks but then began again a day after and continued to have intermittent bleeding for another 2 weeks. Her bleeding stopped entirely 1 week ago. She denies having intercourse since prior to her MVA. Her current symptoms began ___ in her RLQ occasionally radiating to her right upper back. She has taken ibuprofen 800 mg Q8-12 hours since ___ with no improvement in symptoms. Denies any vaginal bleeding, fevers, night sweats, change in vaginal discharge. Has been tolerating PO without nausea vomiting, though has not eaten anything today due to the pain. She therefore presented to urgent care today at which time pelvic ultrasound revealed, "small amount of fluid distending the endometrial cavity. The anterior endometrial wall is thickened and markedly hypervascular, suggesting retained products of conception given the history. The area of presumed retained products measures approximately 3.4 x 3.3 x 1.9 cm." She was then instructed to present to the ED. Of note, she was admitted in ___ for a right kidney stone found on CT. She was aggressively conservatively managed, but had no improvement in symptoms and therefore was treated with a right stent. She again had no improvement and therefore treated with a right stent exchange and laser lithotripsy and then had entire resolution of her symptoms. She reports her symptoms are similar to her symptoms then. <PAST MEDICAL HISTORY> OB: ___ - SVD x 2, full-term - TAB x 5, D&C x 1 GYN: - LMP: ?mid ___, regular menses once monthly regular flow prior to MVA - STI: remote history of chlamydia x 2, last infection ___ - Sexual activity: not currently sexually active - Pap: denies history of abnormal Pap - Contraception: not currently using anything, previously had patch, IUD x 3, nexplanon PMH: - Depression, previously on sertraline PSH: - D&C x 1 - Manual vacuum aspiration x 4 - Right urethral stent exachange and laser lithotripsy <SOCIAL HISTORY> ___ <FAMILY HISTORY> Non contributory <PHYSICAL EXAM> Vitals: VSS Gen: NAD, A&O x 3 CV: RRR Resp: no acute respiratory distress Abd: soft, appropriately tender, no rebound/guarding Ext: no TTP <PERTINENT RESULTS> ___ 01: 30PM BLOOD WBC-11.1* RBC-4.12 Hgb-13.0 Hct-38.0 MCV-92 MCH-31.6 MCHC-34.2 RDW-11.5 RDWSD-38.9 Plt ___ ___ 05: 30PM BLOOD WBC-8.0 RBC-3.79* Hgb-12.0 Hct-35.7 MCV-94 MCH-31.7 MCHC-33.6 RDW-11.9 RDWSD-41.4 Plt ___ ___ 01: 30PM BLOOD Neuts-55.4 ___ Monos-7.9 Eos-0.4* Baso-0.3 Im ___ AbsNeut-6.15* AbsLymp-3.94* AbsMono-0.88* AbsEos-0.04 AbsBaso-0.03 ___ 05: 30PM BLOOD Neuts-51.5 ___ Monos-7.9 Eos-0.6* Baso-0.3 Im ___ AbsNeut-4.10 AbsLymp-3.13 AbsMono-0.63 AbsEos-0.05 AbsBaso-0.02 ___ 05: 30PM BLOOD ___ PTT-34.4 ___ ___ 05: 30PM BLOOD Glucose-83 UreaN-7 Creat-0.5 Na-137 K-3.4 Cl-101 HCO3-25 AnGap-14 ___ 01: 35PM BLOOD HCG-896 ___ 05: 30PM BLOOD CRP-0.4 ___ 12: 10PM URINE Color-Yellow Appear-Clear Sp ___ ___ 12: 10PM URINE Blood-TR Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-0.2 pH-7.5 Leuks-NEG ___ 12: 10PM URINE ___ Bacteri-OCC Yeast-NONE ___ 12: 10PM URINE UCG-POSITIVE * <MEDICATIONS ON ADMISSION> ibuprofen PRN <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 six (6) hours Disp #*30 Tablet Refills: *1 2. Docusate Sodium 100 mg PO BID constipation RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day Disp #*30 Capsule Refills: *1 3. Ibuprofen 600 mg PO Q6H: PRN Pain - Severe Take medication with food RX *ibuprofen 600 mg 1 tablet(s) by mouth every six (6) hours Disp #*30 Tablet Refills: *2 4. OxyCODONE (Immediate Release) 5 mg PO Q6H: PRN Pain - Severe Do not drive or operate heavy machinery while on this medication RX *oxycodone 5 mg 1 capsule(s) by mouth every six (6) hours Disp #*10 Capsule Refills: *0 <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> Retained Products of Conception <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Dear Ms. ___, You were admitted to the gynecology service 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 2 weeks * You may eat a regular diet. * You may walk up and down stairs. Call your doctor for: * fever > 100.4F * severe abdominal pain * difficulty urinating * vaginal bleeding requiring >1 pad/hr * abnormal vaginal discharge * redness or drainage from incision * nausea/vomiting where you are unable to keep down fluids/food or your medication To reach medical records to get the records from this hospitalization sent to your doctor at home, call ___.
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On ___, Ms. ___ was admitted to the gynecology service for planned dilation and curettage on ___ for retained products of conception. Please see the operative report for full details. Her post-operative course was uncomplicated. Immediately post-operatively, her pain was controlled with IV dilaudid and Tylenol. She did receive a dose of doxycycline following the procedure. She was transitioned to PO tylenol and oxycodone on post operative day 0. 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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11123865-DS-10
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Tricor / prednisone / coedine / bupropiom hcl / buspirone / amlodipine / morphine / Lamictal / amoxicillin <ATTENDING> ___ <CHIEF COMPLAINT> vaginal prolapse <MAJOR SURGICAL OR INVASIVE PROCEDURE> posterior colporraphy, enterocele repair with insertion of biologic graft <HISTORY OF PRESENT ILLNESS> Mrs. ___ is a ___ yo Gravida 2 Para 1 who initially presented in office for a consultation requested by Dr. ___ vaginal prolapse. She is complaining of vaginal bulge that she noticed about 3 weeks ago. It is not painful or affecting her quality of life. She denies any needs to splint, no constipation or difficulty with bowel movements. On the contrary in ___ she had a an InterStim procedure performed which helped with her chronic issue with fecal incontinence. This has been a great improvement in her quality of life. She had an episode of postoperative induced mania that is controlled on lithium now She denies any urinary incontinence events. She voids ___ times per day and ___ times per night. Mrs. ___ is not sexually active and does not experience dyspareunia. She denies any vaginal dryness. She is otherwise without any other significant complaints. <PAST MEDICAL HISTORY> PAST MEDICAL HISTORY: 1. Hypertension 2. COPD 3. Hyperlipidemia 4. Bipolar disorder 5. Fibromyalgia PAST SURGICAL HISTORY 1. InterStim (___) 2. Left knee 3. Left wrist PAST OB HISTORY G2P1011 Vaginal: 1 PAST GYN HISTORY She is Postmenopausal and denies any post-menopausal bleeding. <SOCIAL HISTORY> ___ <FAMILY HISTORY> Her family history is remarkable for Breast cancer in her paternal aunt and colon cancer in her grandmother. No ovarian or colon cancer. <PHYSICAL EXAM> Day of initial presentation: Neuro/Psych: Oriented x3, Affect Normal, NAD. Nodes: No inguinal adenopathy. Heart: No pedal edema Lungs: Normal respiratory effort. Abdomen: Non tender, Non distended, No masses, guarding or rebound, No hepatosplenomegaly, No hernia. Ext: No clubbing, cyanosis, edema. Urethra meatus central, no prolapse. Vagina: No lesions, Bladder non-tender, no masses appreciated. Cervix: no lesions, no discharge Uterus: non-tender Adnexa: no masses non tender. POP-Q Exam: Aa: -1.5 Ba: -1.5 TVL: 10 D: -9 C: -8 ___: 3 PB: 2 Ap: +0.5 Bp: +0.5 ___- ___ STAGE Cystocele: 1 Uterus/Cervix: Vault: Ant enterocele: Post enterocele: Rectocele: 2 VAGINAL EXAM - There was no vaginal atrophy Day of discharge: General: NAD CV: Could not hear heart sounds over loud wheezing Lungs: Pronounced expiratory wheezes with abdominal breathing Abdomen: soft, nontender, nondistended, no rebound/guarding GU: No pad, blood on underwear Extremities: no edema, no calf tenderness/erythema/swelling, pneumoboots in place bilaterally <PERTINENT RESULTS> EKG within normal limits ___ <MEDICATIONS ON ADMISSION> The Preadmission Medication list may be inaccurate and requires futher investigation. 1. Albuterol Inhaler ___ PUFF IH Q4H: PRN SOB 2. Diazepam 5 mg PO Q12H: PRN anxiety 3. DICYCLOMine 10 mg PO DAILY: PRN colitis symptoms 4. fluticasone-vilanterol 100-25 mcg/dose inhalation BID 5. Gabapentin 600 mg PO QHS 6. Gabapentin 300 mg PO NOON AS NEEDED for anxiety 7. HydrOXYzine 25 mg PO TID: PRN eczema 8. Levothyroxine Sodium 100 mcg PO DAILY 9. Lisinopril 10 mg PO DAILY 10. Lithium Carbonate CR (Eskalith) 900 mg PO QHS 11. LOPERamide 2 mg PO QID: PRN diarrhea 12. Latuda (lurasidone) 80 mg oral QHS 13. omega-3 acid ethyl esters 1 gram oral DAILY 14. Pramipexole 0.5 mg PO BID 15. Prochlorperazine 10 mg PO Q6H: PRN nausea 16. Temazepam 15 mg PO QHS: PRN insomnia 17. Tiotropium Bromide 1 CAP IH BID 18. Triamcinolone Acetonide 0.1% Cream 1 Appl TP TID 19. Aspirin 81 mg PO DAILY <DISCHARGE MEDICATIONS> 1. Acetaminophen ___ mg PO Q6H: PRN Pain - Mild do not exceed 4000mg in 24 hours RX *acetaminophen 500 mg ___ tablet(s) by mouth every 6 hours Disp #*50 Tablet Refills: *0 2. Cyclobenzaprine 10 mg PO TID muscle spasms do not drink alcohol or drive while taking this medication; causes sedation RX *cyclobenzaprine 10 mg 1 tablet(s) by mouth every 8 hours Disp #*30 Tablet Refills: *0 3. Docusate Sodium 100 mg PO BID RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day Disp #*50 Capsule Refills: *0 4. GuaiFENesin ___ mL PO Q6H RX *guaiFENesin ___ ml by mouth every four hours as needed Disp #*1 Bottle Refills: *0 5. OxyCODONE (Immediate Release) ___ mg PO Q4H: PRN Pain - Severe Reason for PRN duplicate override: Alternating agents for similar severity do not drink alcohol or drive while taking this medication; causes sedation RX *oxycodone 5 mg 1 tablet(s) by mouth every 4 hours Disp #*30 Tablet Refills: *0 6. Albuterol Inhaler ___ PUFF IH Q4H: PRN SOB 7. Aspirin 81 mg PO DAILY 8. Diazepam 5 mg PO Q12H: PRN anxiety 9. DICYCLOMine 10 mg PO DAILY: PRN colitis symptoms 10. fluticasone-vilanterol 100-25 mcg/dose inhalation BID 11. Gabapentin 300 mg PO NOON AS NEEDED for anxiety 12. Gabapentin 600 mg PO QHS 13. HydrOXYzine 25 mg PO TID: PRN eczema 14. Latuda (lurasidone) 80 mg oral QHS 15. Levothyroxine Sodium 100 mcg PO DAILY 16. Lisinopril 10 mg PO DAILY 17. Lithium Carbonate CR (Eskalith) 900 mg PO QHS Eskalith CR 18. LOPERamide 2 mg PO QID: PRN diarrhea 19. omega-3 acid ethyl esters 1 gram oral DAILY 20. Pramipexole 0.5 mg PO BID 21. Prochlorperazine 10 mg PO Q6H: PRN nausea 22. Temazepam 15 mg PO QHS: PRN insomnia 23. Tiotropium Bromide 1 CAP IH BID 24. Triamcinolone Acetonide 0.1% Cream 1 Appl TP TID <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> rectocele enterocele <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. Incision care: * You have a vaginal incision. No tub baths for 6 weeks or until approved by your physician. You may shower as usual. 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 posterior colporrhaphy, enterocele repair with insertion of biologic graft. Please see the operative report for full details. Immediately post-op, her pain was controlled with IV Dilaudid and Toradol. Overnight after post-operative day 0, patient developed an oxygen requirement, and desaturated to 81% when taken off oxygen. Once given oxygen, patient's saturated immediately improved to 95-97% on 2 liters nasal cannula. Patient reported wheezing, mild shortness of breath, anxiety, and a mild cough which she has had since before surgery at this time. On exam, patient had mild increased work of breathing and diffuse expiratory wheezing throughout lung fields bilaterally. Of note, patient has an extensive history of tobacco use and known COPD, followed closely by pulmonology. Team believed her desaturations were secondary to these conditions, and likely exacerbated by recent anesthesia, narcotics, and pre-existing cough. There was a low concern for a pulmonary embolus based on history. Patient was given 1 albuterol nebulizer overnight, earlier administration of her home COPD medications, guaifenesin for cough. An EKG showed sinus tachycardia with nonspecific ST changes, minimal change from prior EKG in ___. Tachycardia thought to be due to albuterol nebulizer and anxiety. Patient refused use of CPAP overnight. In the morning of post-operative day 1, patient received second nebulizer albuterol and her breathing and saturations improved. Her urine output was adequate, and in the afternoon of post-operative day 1, her Foley was removed with a voiding trial, the results of which are as follows: 1. Instilled 300 mL, voided 50cc and then fifteen minutes later, 450 mL with 0 mL residual. By the late afternoon of post-operative day 1, she was tolerating a regular diet, ambulating independently, and pain was controlled with oral medications. She was then discharged home in stable condition with outpatient follow-up scheduled.
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11125208-DS-12
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Penicillins <ATTENDING> ___. <CHIEF COMPLAINT> pelvic pain <MAJOR SURGICAL OR INVASIVE PROCEDURE> 1. Laparotomy. 2. Extensive pelvic adhesiolysis. 3. Supracervical hysterectomy. <HISTORY OF PRESENT ILLNESS> The patient is a ___ G0 sent by Dr. ___ for a consultation regarding uterine fibroids. The patient has a long history of uterine fibroids and underwent a uterine artery embolization in ___. This did shrink the fibroids per the patient's report, but they have apparently grown since then. Recently, she presented to ___ with acute right lower quadrant pain. She was evaluated with a CT of the abdomen and pelvis. This revealed a large bulky mass extending from the pelvis consistent with fibroids. Also mentioned in the report was some question of omental caking or small area of ascites as well as a question of caking of the mesentery. There was a low-attenuation lesion in the right lobe of the liver, but apparently the patient is known to have focal nodular hyperplasia of the liver. She also had an ultrasound which demonstrated a very large uterus with multiple fibroids. There was mild hydronephrosis of a transplanted kidney in the right pelvis. The patient has been advised by Dr. ___ to consider hysterectomy given the likely extrinsic compression on the transplanted kidney by the uterine fibroids. She states that she has residual discomfort but the acute pain has resolved. She states that her menses have been regular with no intermenstrual bleeding and no menorrhagia. <PAST MEDICAL HISTORY> Systemic lupus with resulting renal failure requiring kidney transplantation in ___, hypertension <SOCIAL HISTORY> ___ <FAMILY HISTORY> Significant for mother with unspecified cancer. <PHYSICAL EXAM> GENERAL: Well-developed, well-nourished. HEENT: Sclerae anicteric. LYMPHATICS: Lymph node survey was negative. LUNGS: Clear to auscultation. HEART: Regular without murmurs. ABDOMEN: Soft and nondistended. There was a palpable mass in the left side of the lower abdomen extending to near the umbilicus consistent with a uterine fibroid. There was a palpable mass in the right lower quadrant consistent with a transplanted kidney. EXTREMITIES: Without edema. PELVIC: The vulva and vagina were normal. The cervix was not immediately visualized on speculum examination. Bimanual and rectovaginal examination revealed that the cervix was involved with a very large fibroid measuring at least 10 cm. The cervix and mass in the left lower abdomen moved in continuity suggesting that there were further fibroids above the cervix. There were no separately palpable adnexal masses. There was no cul-de-sac nodularity, and the rectum was intrinsically normal. <PERTINENT RESULTS> HEMATOLOGY ========== ___ 08: 15AM BLOOD WBC-7.9# RBC-3.36* Hgb-10.4* Hct-31.3* MCV-93 MCH-31.1 MCHC-33.4 RDW-13.7 Plt ___ ___ 08: 00AM BLOOD WBC-9.8 RBC-3.28* Hgb-10.0* Hct-30.9* MCV-94 MCH-30.5 MCHC-32.4 RDW-13.8 Plt ___ ___ 08: 00AM BLOOD Neuts-80.2* Lymphs-10.6* Monos-9.1 Eos-0.1 Baso-0 . CHEMISTRY ========= ___ 08: 00AM BLOOD Glucose-111* UreaN-5* Creat-0.9 Na-140 K-4.0 Cl-107 HCO3-27 AnGap-10 ___ 08: 00AM BLOOD Calcium-8.5 Phos-2.0* Mg-1.3* ___ 06: 40AM BLOOD Glucose-102 UreaN-4* Creat-0.8 Na-141 K-4.0 Cl-108 HCO3-29 AnGap-8 ___ 06: 40AM BLOOD Calcium-8.1* Phos-2.1* Mg-1.4* . URINANALYSIS ============ ___ 01: 43AM URINE Color-Straw Appear-Clear Sp ___ ___ 01: 43AM URINE Blood-MOD Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG ___ 01: 43AM URINE RBC-<1 WBC-<1 Bacteri-FEW Yeast-NONE Epi-1 . MICROBIOLOGY ============ ___ Urine Culture: No growth (contaminated specimen) . <MEDICATIONS ON ADMISSION> Amlodipine, metoprolol, potassium citrate, prednisone, tacrolimus, calcium, multivitamins. <DISCHARGE MEDICATIONS> 1. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 3. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Tacrolimus 5 mg Capsule Sig: One (1) Capsule PO Q12H (every 12 hours). 5. Tacrolimus 1 mg Capsule Sig: One (1) Capsule PO Q12H (every 12 hours). 6. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO QID (4 times a day) as needed. 7. Oxycodone-Acetaminophen ___ mg Tablet Sig: ___ Tablets PO every ___ hours as needed for pain: maximum daily Tylenol (acetaminophen) is 4000mg, each Percocet contains 325mg Tylenol (acetaminophen). Disp: *60 Tablet(s)* Refills: *0* 8. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day as needed for constipation. Disp: *60 Capsule(s)* Refills: *0* <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> fibroid uterus <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 for 2 weeks (no tampons, no douching, no sex), no heavy lifting of objects >10lbs for 6 weeks. * You may eat a regular diet. . Incision care: * You may shower and allow soapy water to run over incision; no scrubbing of incision. No bath tubs for 6 weeks. * If you have steri-strips, leave them on. They will fall off on their own or be removed during your followup visit .
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Ms. ___ was admitted after undergoing laparotomy, extensive pelvic adhesiolysis, and supracervical hysterectomy. Please see operative note for complete details. Her post-operative course was characterized by the following issues: . 1. Nausea Ms. ___ experienced some nausea on post-operative day 1, which resolved with a decrease in her narcotics use. . 2. Fever On the evening of post-operative day 2 Ms. ___ developed a temperature which reached a max of 101.8 degrees. She had a negative urinalysis and no growth in urine cultures (contaminated specimen). There were no focal signs of infection. Her temperature decreased over the following day, and the fever was resolved by the morning of post-op day 3. She was afebrile for 24 hours prior to discharge. . Ms. ___ was discharged on post-operative day 3 in stable condition: afebrile, able to eat regular food, under adequate pain control with oral medications, and ambulating and urinating without difficulty.
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11125220-DS-12
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> vaginal bleeding and cramping <MAJOR SURGICAL OR INVASIVE PROCEDURE> dilation and curettage <HISTORY OF PRESENT ILLNESS> ___ s/p D&C versus medical management of SAB of twins at "3 months" ___ in ___ presenting with irregular vaginal bleeding and abdominal cramping since the SAB. The patient is unclear whether or not she had a D&C or medical management but thinks she received abx and pain medication. Most recent episode of bleeding was ___ and lasted a few hours. She has had worsening cramping since then and went to ___ for evaluation where an HCG was found to be 22 and an ultrasound was concerning for vascularized RPOCs and she was sent to ___ for further management. Here reports minimal ongoing bleeding and denies significant pain. Reports some discomfort with urination. Denies N/V. Denies abnl discharge. Denies F/C. <PAST MEDICAL HISTORY> Ob Hx: - TAB x 1 - ___ tri in ___ - same partner, no ___ - SAB of twins at ___ - "3 months" - found out she was pregnant in ___ and lost pregnancy ___ Gyn Hx: regular menses, denies hx STIs, has never had gyn care in ___ - unknown Pap hx PMH: denies PSH: ?D&C <SOCIAL HISTORY> ___ <FAMILY HISTORY> noncontributory <PHYSICAL EXAM> Initial Physical Exam O: T 98.2 HR 66 BP 105/58 RR 16 O2 100%RA NAD, well-appearing RRR CTAB Abd soft, ND, diffuse TTP in lower quadrants, no rebound or guarding SSE: small amt of blood in vault cleared easily with 2 scopettes, no active vaginal bleeding, external os slightly open, no abnl discharge ___&CT collected Pelvic: approx 12cm uterus, diffusely and mildly tender to palpation, no CMt, anteverted, nl adnexa Physical Exam on Day of Discharge GEN: NAD CV: RRR LUNGS: CTAB ABD: s, nd, appropriately tender in lower quadrants, no r/g EXT: wwp, nt, no edema VB minimal <PERTINENT RESULTS> ___ 04: 35AM BLOOD WBC-7.2 RBC-5.31 Hgb-11.9* Hct-38.5 MCV-73* MCH-22.5* MCHC-30.9* RDW-12.7 Plt ___ ___ 03: 49PM BLOOD WBC-6.2 RBC-5.18 Hgb-11.6* Hct-38.2 MCV-74* MCH-22.3* MCHC-30.3* RDW-12.7 Plt ___ ___ 04: 35AM BLOOD Neuts-60.5 ___ Monos-5.1 Eos-3.3 Baso-1.3 ___ 03: 49PM BLOOD ___ PTT-27.6 ___ ___ 04: 35AM BLOOD Glucose-102* UreaN-9 Creat-0.7 Na-137 K-3.6 Cl-106 HCO3-27 AnGap-8 ___ 04: 35AM BLOOD HCG-20 <MEDICATIONS ON ADMISSION> none <DISCHARGE MEDICATIONS> 1. Acetaminophen ___ mg PO Q6H: PRN pain do not take over 4000mg in 24 hours RX *acetaminophen 500 mg ___ tablet(s) by mouth no more frequently than every 6 hours Disp #*45 Tablet Refills: *1 <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> General instructions: * Take your medications as prescribed. * Do not drive while taking narcotics. * Take a stool softener such as colace while taking narcotics to prevent constipation * Do not combine narcotic and sedative medications or alcohol * Do not take more than 4000mg acetaminophen (APAP) in 24 hrs * No strenuous activity until your post-op appointment * Nothing in the vagina (no tampons, no douching, no sex) for 2 weeks * No heavy lifting of objects >10lbs for 2 weeks. * You may eat a regular diet * You may shower and allow soapy water to run over incision; no scrubbing of incision. No bath tubs for 2 weeks. To reach medical records to get the records from this hospitalization sent to your doctor at home, call ___.
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On ___, Ms. ___ was admitted to the gynecology service after undergoing a dilation and curettage for retained products of conception. 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 tylenol. A uterine foley was placed intraoperatively for hemostasis. On post-operative day 1, her bleeding was well controlled and her uterine foley was removed. 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 pain medication by mouth. 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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11125220-DS-13
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> induction of labor for post-dates <MAJOR SURGICAL OR INVASIVE PROCEDURE> Low transverse cesarean section <HISTORY OF PRESENT ILLNESS> ___, G3P0 who presented at 41 weeks and 0 days for postdates induction of labor that was undertaken with misoprostol followed by Pitocin. She underwent artificial rupture of membranes at 1430 on ___. Subsequently, she began to dilate from her starting exam of 5 cm and high, eventually to a rim; however, the fetal vertex remained quite high in the pelvis, descending only to -1 station with significant kaput concerning for CPD despite cervical change over multiple exams. The patient developed chorioamnionitis and remained febrile despite triple antibiotic therapy, and the fetal status was no longer reassuring with persistent tachycardia, recurrent leads, and attempted scalp stimulation resulted in deceleration, therefore, the patient was counseled for recommendation of cesarean delivery. <PAST MEDICAL HISTORY> Ob Hx: - TAB x 1 - ___ tri in ___ - same partner, no ___ - SAB of twins at ___ - "3 months" - found out she was pregnant in ___ and lost pregnancy ___ Gyn Hx: regular menses, denies hx STIs, has never had gyn care in ___ - unknown Pap hx PMH: denies PSH: ?D&C <SOCIAL HISTORY> ___ <FAMILY HISTORY> noncontributory <PHYSICAL EXAM> VSS, oxygen saturation >96% RA NAD Lungs CTAB Abdomen soft, NT, ND. Incision c/d/i. Extremities WWP, no edema <PERTINENT RESULTS> ___ 07: 10AM BLOOD WBC-10.8 RBC-4.30 Hgb-10.5* Hct-32.3* MCV-75* MCH-24.4* MCHC-32.5 RDW-14.3 Plt ___ ___ 04: 15AM BLOOD WBC-12.0*# RBC-4.34 Hgb-10.4* Hct-31.9* MCV-74* MCH-23.9* MCHC-32.5 RDW-14.4 Plt ___ ___ 01: 01AM BLOOD WBC-6.3 RBC-5.10 Hgb-12.6 Hct-38.1 MCV-75* MCH-24.7* MCHC-33.0 RDW-14.7 Plt ___ ___ 04: 15AM BLOOD Neuts-87.1* Lymphs-7.4* Monos-4.9 Eos-0.4 Baso-0.2 ___ 07: 10AM BLOOD Plt ___ ___ 04: 15AM BLOOD Plt ___ ___ 01: 01AM BLOOD Plt ___ ___ 04: 15AM BLOOD Glucose-94 UreaN-9 Creat-0.7 Na-136 K-4.0 Cl-103 HCO3-25 AnGap-12 ___ 03: 31AM BLOOD Creat-1.1 ___ 04: 15AM BLOOD proBNP-726* ___ 04: 15AM BLOOD Calcium-8.0* Phos-3.3 Mg-1.7 <MEDICATIONS ON ADMISSION> The Preadmission Medication list is accurate and complete. 1. Prenatal Vitamins 1 TAB PO DAILY <DISCHARGE MEDICATIONS> 1. Docusate Sodium 100 mg PO BID: PRN Constipation Take with narcotic pain medications RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day Disp #*40 Capsule Refills: *2 2. norethindrone (contraceptive) 0.35 mg oral daily RX *norethindrone (contraceptive) 0.35 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills: *2 3. Acetaminophen ___ mg PO Q4H: PRN Pain RX *acetaminophen 650 mg 1 tablet(s) by mouth every 6 hours Disp #*60 Tablet Refills: *2 4. OxycoDONE (Immediate Release) 5 mg PO Q4H: PRN pain RX *oxycodone 5 mg 1 tablet(s) by mouth every 4 hours Disp #*60 Tablet Refills: *0 <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> Cesarean section Chorioamnonitis, resolved Shortness of breath, without evidence of heart failure or pulmonary embolus Acute kidney injury which has resolved <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Dear ___, Congratulations on your delivery! You are safe to go home. Please follow 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 Percocet Do not take more than 4000mg acetaminophen (APAP) in 24 hrs Do not take more than 2400mg ibuprofen in 24 hrs Please call the on-call doctor at ___ if you develop shortness of breath, dizziness, palpitations, fever of 101 or above, abdominal pain, increased redness or drainage from your incision, nausea/vomiting, heavy vaginal bleeding, or any other concerns.
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Ms. ___ underwent a low transverse cesarean section on ___ for a failed induction of labor. Please see operative report for full details. Her labor course was complicated by an intrapartum fever and she was treated for chorioamnionitis with triple antibiotic therapy. When she remained febrile desptie treatment, she was given flagyl and unasyn for 24 hours afebrile. She developed acute kidney injury due to hypovolemia after having a high blood loss intraoperatively. This resolved with IV fluids. On post-operative day 1, she complained of shortness of breath on exertion and had hypoxemia with oxygen saturations from 89% to 95%. Given her history of shortness of breath at the end of pregnancy, there was concern for postpartum cardiomyopathy. Her ECG was normal and a chest x-ray showed a heart size at the upper limit of normal. A CTA was also done to rule out a pulmonary embolus, which was negative for PE but also showed a normal heart size. An echo was therefore deferred. Her symptoms were thought to be due to fluid overload and resolved after autodiuresis.
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11125928-DS-22
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Penicillins / Ampicillin / Vancomycin / Combigan <ATTENDING> ___ <CHIEF COMPLAINT> Pelvic organ prolapse, stress urinary incontinence <MAJOR SURGICAL OR INVASIVE PROCEDURE> Robotic-assisted supracervical hysterectomy, bilateral salpingo-oophorectomy, sacrocolpopexy, suburethral sling, 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 <DISCHARGE INSTRUCTIONS> Dear Ms. ___, You were admitted to the gynecology service after your procedure. You have recovered well and the team believes you are ready to be discharged home. Please call Dr. ___ office with any questions or concerns. Please follow the instructions below. General instructions: * Take your medications as prescribed. * Do not drive while taking narcotics. * Take a stool softener such as colace while taking narcotics to prevent constipation. * Do not combine narcotic and sedative medications or alcohol. * Do not take more than 4000mg acetaminophen (APAP) in 24 hrs. * No strenuous activity until your post-op appointment. * Nothing in the vagina (no tampons, no douching, no sex) for 6 weeks. * If TLH/TVH: Nothing in the vagina (no tampons, no douching, no sex) for 3 months. * No heavy lifting of objects >10 lbs for 6 weeks. * You may eat a regular diet. * You may walk up and down stairs. Incision care: * You may shower and allow soapy water to run over incision; no scrubbing of incision. No tub baths for 6 weeks. * If you have steri-strips, leave them on. They will fall off on their own or be removed during your followup visit. Call your doctor for: * fever > 100.4F * severe abdominal pain * difficulty urinating * vaginal bleeding requiring >1 pad/hr * abnormal vaginal discharge * redness or drainage from incision * nausea/vomiting where you are unable to keep down fluids/food or your medication To reach medical records to get the records from this hospitalization sent to your doctor at home, call ___.
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On ___, Ms. ___ was admitted to the gynecology service after undergoing a robotic-assisted supracervical hysterectomy, bilateral salpingo-oophorectomy, sacrocolpopexy, suburethral sling, and cystoscopy. Please see the operative report for full details. Her post-operative course was uncomplicated. Immediately post-op, her pain was controlled with IV morphine and toradol prn. Her diet was advanced without difficulty and she was transitioned to PO tramadol and ibuprofen prn. On post-operative day 1, her urine output was adequate so her foley was removed and she voided spontaneously. She was continued on her home medications for hypertension and hyperlipidemia. 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. Docusate Sodium 100 mg PO BID 2. Ibuprofen 400 mg PO Q8H:PRN Pain - Moderate Reason for PRN duplicate override: Alternating agents for similar severity take with food 3. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain - Moderate may cause sedation. do not drink alcohol or drive while taking oxycodone 4. Aspirin 81 mg PO DAILY 5. irbesartan 150 mg oral DAILY 6. Omeprazole 20 mg PO DAILY 7. Ranitidine 150 mg PO DAILY 8. Rosuvastatin Calcium 10 mg PO QPM 9. Triamterene-HCTZ (37.5/25) 1 CAP PO DAILY Discharge Disposition: Home Discharge Diagnosis: Pelvic organ prolapse, stress urinary incontinence Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___
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11128272-DS-19
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Prilosec / Compazine / NSAIDS (Non-Steroidal Anti-Inflammatory Drug) <ATTENDING> ___. <CHIEF COMPLAINT> transfer from ___ for anhydramnios <MAJOR SURGICAL OR INVASIVE PROCEDURE> repeat LTCS <HISTORY OF PRESENT ILLNESS> Pt is a ___ y/o G3P1 @ 36wks by ___ US presenting via ambulance transfer from ___ for a new finding of anhydramnios in the setting of maternal motrin use. She reports she has been getting routine prenatal care at ___ (Dr. ___. Per report over the past 2wks she reports she started to use 400mg motrin BID at the recommendation of her OB for a recent sore right ankle. She reports she presented to ___ today because she was concerned that she has not had an US since ___. At ___ today she underwent an US showing anhydramnios, ?absent kidneys, no fluid filled stomach and no bladder. She had a BPP ___ (no fluid). Then she was transferred to ___ At ___, she reports she feels overall well. She denies any LOF, VB, contractions. She reports the fetus is moving normally. She denies any fevers, chills, cough, CP/SOB/abdominal pain. Dating: ___ ___ by 6wks US Anatomy US at 18wk, normal appearing, limited views of outflow tracks, 3VC, kidneys normal <PAST MEDICAL HISTORY> OB Hx: ___: SAB 10wks ___: LTCS, failed IOL, girl PMHx: Acid Base Ulcer Disease Crohns Disease Opioid dependance PSHx: ___: LTCS, term, failed IOL Ex lap and repair of duodenal ulcer ___, ___ Ex lap, selective vagotomy, appendectomy, cholecystectomy, ___, CHA LTCS <SOCIAL HISTORY> Opioid dependance on Burpenorphine <PHYSICAL EXAM> On admission 98.3, 65, 18, 137/___ppearing +s1s2 CTA B/L Well healed vertical midline incision, well healed ___ incision. No epigastric tenderness No fundal tenderness Normal appearing external female genitalia, no lesions No pool, cervix closed appearing, normal appearing physiologic discharge No ferns, Nitrazine negative On Discharge: Afebrile, VSS Gen: NAD CV: RRR Pulm: CTAB Abd: soft, appropriately tender, fundus firm, no R/G Ext: no TTP Incision: ___ c/d/i <PERTINENT RESULTS> ___ 7: 30 pm ANORECTAL/VAGINAL CULTURE Source: Anorectal/Vaginal. **FINAL REPORT ___ R/O GROUP B BETA STREP (Final ___: NEGATIVE FOR GROUP B BETA STREP. Bed US ___: cephalic, AFI zero, BPP ___ (no fluid) normal appear kidneys B/L, stomach not visualized, small bladder, 3VC, normal appearing four chamber, LVOT, RVOT, cord insertion. EFW 2951g ___ 08: 10PM BLOOD WBC-5.6 RBC-3.77* Hgb-9.7* Hct-28.8* MCV-77* MCH-25.7* MCHC-33.6 RDW-13.4 Plt ___ ___ 10: 39PM BLOOD pO2-21* pCO2-45 pH-7.34* calTCO2-25 Base XS--2 Comment-CORD VEIN ___ 10: 34PM BLOOD pO2-17* pCO2-98* pH-7.03* calTCO2-28 Base XS--10 ___ 06: 07AM BLOOD Hct-23.6* ___ 08: 46PM URINE bnzodzp-NEG barbitr-NEG opiates-NEG cocaine-NEG amphetm-NEG mthdone-NEG <DISCHARGE INSTRUCTIONS> Dear Ms ___, . Please follow the instructions below for your post partum care: . Nothing in the vagina for 6 weeks (No sex, douching, tampons) No heavy lifting for 6 weeks Do not drive while taking Dilaudid Do not take more than 4000mg acetaminophen (APAP) in 24 hrs Do not take more than 2400mg ibuprofen in 24 hrs Please call your OB/GYN (Dr. ___ or the on-call doctor at ___ ___ if you develop shortness of breath, dizziness, palpitations, fever of 101 or above, abdominal pain, increased redness or drainage from your incision, nausea/vomiting, heavy vaginal bleeding, or any other concerns.
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MS. ___ is a ___ yo G3P1 @ ___ by 6wk US who was transferred from ___ for a new finding of anhydramnios in the setting of maternal NSAID use. Upon evaluation, there was no evidence of PPROM. The fetus was well grown with ___ BPP. Given that the AFI was zero and a gestational age of ___ weeks, delivery was recommended. Risk and benefits of delivery were reviewed with the patient. The risk/benefits of TOLAC vs. LTCS was also discussed and the patient elected for a repeat LTCS. She was seen by NICU. Her post op pain medication was discussed with ___ PC (Dr. ___. She underwent a LTCS on ___. Please see the operative note for details FINDINGS: 1. Live-born female infant delivered from the cephalic presentation. 2. No appreciable amniotic fluid. 3. Apparently intact placenta with 3-vessel cord. 4. Normal tubes, ovaries, and uterus. She was seen by chronic pain for her post partum pain management. Her pain was initially managed with Dilaudid PCA and Subutex then transitioned to Dilaudid PO ___ q3h, acetaminophen and low dose ibuprofen. She had an otherwise uncomplicated post-partum course and remained hemodynamically stable. She was discharged in stable condition on post partum day 6 with a week's prescription of narcotic medication and outpatient follow-up. Discharge Medications: 1. Acetaminophen ___ mg PO Q4H:PRN Pain RX *acetaminophen [Acetaminophen Extra Strength] 500 mg ___ tablet(s) by mouth q4-6hr Disp #*60 Tablet Refills:*0 2. Docusate Sodium 100 mg PO BID:PRN Constipation RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day Disp #*60 Capsule Refills:*3 3. HYDROmorphone (Dilaudid) ___ mg PO Q3H:PRN pain RX *hydromorphone 4 mg 1 tablet(s) by mouth q3hrs Disp #*60 Tablet Refills:*0 4. Ibuprofen 400 mg PO Q4H:PRN pain RX *ibuprofen 400 mg 1 tablet(s) by mouth every four (4) hours Disp #*50 Tablet Refills:*1 Discharge Disposition: Home Discharge Diagnosis: s/p repeat C/S, narcotic dependence Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___
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11128272-DS-20
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Prilosec / Compazine / NSAIDS (Non-Steroidal Anti-Inflammatory Drug) <ATTENDING> ___. <CHIEF COMPLAINT> abdominal pain <MAJOR SURGICAL OR INVASIVE PROCEDURE> vaginal delivery <HISTORY OF PRESENT ILLNESS> ___ yo G4P2 w/ hx of chronic abdominal pain, gastritis, and multiple abdominal surgeries (including incarcerated umbilical hernia repair ___ who presents with pelvic pain x2 days. She describes the pain as a constant pressure in the suprapubic region which radiates bilaterally and is 7 out of 10 in intensity. The pain is worsened by movement. Pt reports chronic nausea. She has also had several loose blood-tinged stools over the last few days, which she states is somewhat typical for her, given her reported diagnosis of Crohn's disease (note: per CHA record review, unclear if she has been diagnosed with Crohn's). She denies emesis, fevers, chills, dysuria, hematuria, leakage of fluid, abnormal vaginal discharge, chest pain, shortness of breath, dizziness, lightheadedness. She does report red-tinged mucus with wiping after voids over the last 2 days. Denies recent intercourse or abdominal trauma. She presented to the CHA ED with the aforementioned complaints and underwent a pelvic ultrasound which demonstrated a small abruption and she was discharged home with OB follow-up. She re-presented to the CHA ED with ongoing pain, and the decision was made to proceed with an MRI for further evaluation, and she was subsequently transferred to ___ ED. ROS: as per HPI, otherwise neg <PAST MEDICAL HISTORY> PNC: - ___ LMP ___ -> ___ ___ US ___ (@ 5wks) -> ___ ___ - Labs B+/Abs-/RPRNR/RI/HBsAg-/HCV-/HIV- - Issues *) Placenta previa noted on 13 weeks ultrasound, resolved *) Cystic hygroma -> s/p ___ ___ [ ]fetal echo at 22 wks, monthly growth scans, antenatal BPP/NST weekly after 36 weeks *) Bacteruria (___) ___ staph in urine, treated with macrobid x7 days. UCx ___ neg. OBHx: - G1 SABx1 - G2 pLTCS at term for failure to progress (___) - G3 rLTCS preterm for breech, anhydramnios (___) - G4 current GynHx: - unsure when last pap was - h/o chlamydia (___) - denies hx of fibroids PMH: - ADHD - Bipolar disorder - Gastritis, h/o duodenal ulcer - Convulsions: per OSH record review, in ___ pt had 1 seizure at home and 1 in the ED. MRI was negative - Pyleonephritis (___) c/b renal abscess requiring drainage - ?Crohn's disease: Pt reports hx of Crohn's disease and states that she was on humira prior to pregnancy. Per GI consultation note in ___ (Dr. ___, there was no evidence of Crohn's disease on either EGD or colonoscopy. - History of GI ulcers, gastritis: *) ___ Upper GI endoscopy: lower esophageal ulcers, erythematous mucosa in gastric biopsy, ulcerated duodenal bulb. *) ___ Colonoscopy: Normal throughout, no biopsies taken *) ___ Upper GI endoscopy: A small hiatal hernia was present. Grade B esophagitis (biopsy w/ acute esophagitis w ulceration), proximal gastric body inflammation (biopsy w/ chronic gastritis, no H pylori organisms), non-bleeding erosion at pylorus (biopsy w/ moderate chronic gastritis, scalloped mucosa in second portion of duodenum (biopsy w/ milr villous blunting with focally increased intraepithelial lymphocytes..."features raised the possibility of celiac spruce) --> tTransglutaminase testing negative PSH: - C-section x2 - exploratory laparotomy, repair of duodenal ulcer (___) - exploratory laparotomy, highly selective vagotomy, cholecystectomy, appendectomy (___) - repair of incarcerated umbilical hernia with mesh (___) <SOCIAL HISTORY> ___ <FAMILY HISTORY> family history of Crohn's disease (mother, grandmother) <PHYSICAL EXAM> On admission: 97.9 97 126/64 16 100% on RA Gen - NAD CV - regular rate Pulm - nl respiratory effort Abd - no upper abdominal TTP, anticipatory RLQ tenderness +guarding, moderate midline pelvic and LLQ tenderness to palpation (unable to assess for rebound due to pt discomfort, however pt denied increased discomfort with shaking the stretcher) SSE - nl external female genitlia, copious brown/yellow opaque liquid-consistency discharge in vault (6 scopettes cleared), no cervical/vaginal lesions. cervical os closed SVE - deferred IMAGING - ___ CHA Ultrasound: Single fetus in breech presentation. The placenta is posterior with no evidence of previa. Small marginal placental abruption measuring 1.2 x 1 x 1.1 cm, similar to the previous examination. The fetal heart rate is 147 bpm. The cervix is long and closed. Age by the estimated due date of ___ is 19 weeks 0 days. Impression: 1. Small acute marginal placental abruption, similar to the previous study. 2. Single live intrauterine pregnancy, size equal dates. - ___ ___ MRI: 1. Small placental abruption centered along the left anterolateral aspect of a predominantly upper posterior placenta. By history this is already known, although finding cannot be directly compared to any prior imaging, since none is available at this time. 2. Limited evaluation of small bowel, which is not distended. This study was performed within appendicitis protocol rather than MR enterography protocol. However, there is no suggestion of small bowel inflammation, and the terminal ileum is fairly well visualized, showing only slight wall thickening. This is nonspecific and quite possibly chronic without edema or inflammatory change. 3. Moderately prominent colonic stool content throughout the colon. 4. Unremarkable postsurgical changes along the anterior abdominal wall. On discharge: ___ ___ Temp: 98.1 PO BP: 166/70 R Lying HR: 73 RR: 18 O2 sat: 99% O2 delivery: Ra ___ 0339 Temp: 98.0 PO BP: 137/89 R Lying HR: 96 RR: 18 O2 sat: 99% O2 delivery: Ra ___ 2315 Temp: 98.6 PO BP: 147/93 HR: 101 RR: 20 O2 sat: 99% O2 delivery: ra ___ 2032 BP: 136/93 HR: 98 ___ Temp: 97.8 Axillary BP: 151/98 HR: 88 RR: 18 O2 sat: 100% O2 delivery: RA ___ 1621 Temp: 98.7 PO BP: 142/82 R Standing HR: 103 RR: 17 O2 sat: 100% O2 delivery: RA ___ 1142 Temp: 98.4 PO BP: 135/87 R Lying HR: 113 RR: 17 O2 sat: 95% O2 delivery: Ra Gen: NAD Abd: ND, minimal tenderness, fundus firm at 1cm below umbilicus Ext: NT <PERTINENT RESULTS> ___ 12: 00PM BLOOD WBC-10.2* RBC-4.00 Hgb-10.5* Hct-33.3* MCV-83 MCH-26.3 MCHC-31.5* RDW-15.6* RDWSD-47.5* Plt ___ ___ 12: 20PM BLOOD WBC-8.0 RBC-4.04 Hgb-10.5* Hct-35.1 MCV-87 MCH-26.0 MCHC-29.9* RDW-15.9* RDWSD-50.7* Plt ___ ___ 12: 20PM BLOOD Neuts-76.0* Lymphs-16.7* Monos-5.2 Eos-1.0 Baso-0.6 Im ___ AbsNeut-6.05 AbsLymp-1.33 AbsMono-0.41 AbsEos-0.08 AbsBaso-0.05 ___ 09: 50AM BLOOD ___ PTT-30.8 ___ ___ 12: 20PM BLOOD ___ PTT-31.4 ___ ___ 09: 50AM BLOOD ___ ___ 12: 20PM BLOOD Glucose-80 UreaN-10 Creat-0.6 Na-136 K-4.2 Cl-109* HCO3-18* AnGap-9* ___ 12: 20PM BLOOD ALT-11 AST-15 AlkPhos-85 TotBili-0.2 ___ 12: 20PM BLOOD Lipase-17 ___ 12: 20PM BLOOD Albumin-3.6 ___ 08: 44PM BLOOD Lactate-0.5 ___ 01: 09PM BLOOD Lactate-2.3* ___ 12: 20PM URINE Color-Yellow Appear-Hazy* Sp ___ ___ 12: 20PM URINE Blood-NEG Nitrite-NEG Protein-30* Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-2* pH-6.5 Leuks-TR* ___ 12: 20PM URINE RBC-4* WBC-4 Bacteri-NONE Yeast-NONE Epi-18 <MEDICATIONS ON ADMISSION> - latuda 80mg QPM - gabapentin 800mg TID - subutex 8mg BID (confirmed dose in ___ medical record, prescribed by Dr. ___ - Adderall 25mg XR BID <DISCHARGE MEDICATIONS> 1. Acetaminophen 650 mg PO Q6H: PRN Pain 2. Docusate Sodium 100 mg PO BID 3. Buprenorphine 8 mg SL BID 4. Gabapentin 800 mg PO TID 5. Latuda (lurasidone) 80 mg oral QHS <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> 19 week pregnancy loss, placental abruption <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Nothing in the vagina for 6 weeks (No sex, douching, tampons) Do not take more than 4000mg acetaminophen (tylenol) in 24 hrs Do not take more than 2400mg ibuprofen in 24 hrs Please call the on-call doctor at ___ if you develop shortness of breath, dizziness, palpitations, fever of 100.4 or above, abdominal pain, heavy vaginal bleeding, nausea/vomiting, depression, or any other concerns.
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Ms. ___ is a ___ yo G4P2 with a history of chronic abdominal pain, gastritis/peptic ulcer disease, opioid abuse, and multiple abdominal surgeries (including incarcerated umbilical hernia repair ___ who was admitted with pelvic pain. She had a MRI done on ___ that showed no evidence of small bowel inflammation, slight wall thickening of terminal ileum (nonspecific changes), moderately prominent colonic stool content. ACS was consulted and determined there were no acute surgical issues. She had a normal white blood cell count. She had an elevated lactate on admission that resolved. Her LFTs and lipase were also WNL. Pelvic ultrasound (___) showed a posterior placenta with no evidence of previa, and a 1.2cm marginal abruption. She began to have worsening pelvic pain after admission to the floor, and developed some brown vaginal discharge that progressed to vaginal bleeding. Her cervix, which was initially closed on sterile speculum exam, progressed to 4 cm. She began contracting more uncomfortably and developed increased vaginal bleeding, concerning for preterm labor and abruption. She delivered a stillborn infant. She was followed by social work during her stay. Psychiatry determined that she did not meet ___ criteria, and was stable for discharge home on her home medications with outpatient follow up. She was continued on her home subutex, latuda, and adderall. She did have some elevated blood pressures post partum (highest 166/70, remaining normal to mild range), likely representing chronic HTN. She was discharged home in stable condition with strict instructions for outpatient follow up.
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11129029-DS-5
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> Headache, blurry vision, nausea <MAJOR SURGICAL OR INVASIVE PROCEDURE> Low transverse cesarean section <HISTORY OF PRESENT ILLNESS> This patient is a ___ year old female who is ___ weeks pregnant, G1, P0, has felt dizziness, blurry vision in both eyes, mild headache since yesterday. Has been having some mild episodes of chest pain at night for the past 3 nights. No vaginal bleeding. + Fetal movements. States has had an uncomplicated pregnancy so far, has not been hypertensive up to this point. <PAST MEDICAL HISTORY> LSGIL s/p appendectomy <SOCIAL HISTORY> ___ <FAMILY HISTORY> Nncontributory <PHYSICAL EXAM> PHYSICAL EXAMINATION Temp: 97.6 HR: 105 BP: 156/107 Resp: 17 O(2)Sat: 97 Constitutional: Comfortable HEENT: Normocephalic, atraumatic, Extraocular muscles intact, Pupils equal, round and reactive to light Chest: Clear to auscultation Cardiovascular: Regular Rate and Rhythm Abdominal: Soft, Nontender Extr/Back: No cyanosis, clubbing or edema Skin: Warm and dry Neuro: Alert and oriented x3, normal cranial nerves ___, no nystagmus, normal finger to nose, no pronator drift, normal extremity motor and light touch, sensory function. Psych: Normal mentation ___: No petechiae <PERTINENT RESULTS> ___ 11: 13PM CREAT-0.6 ___ 11: 13PM ALT(SGPT)-88* AST(SGOT)-121* LD(LDH)-816* TOT BILI-0.5 ___ 11: 13PM cTropnT-<0.01 ___ 11: 13PM URIC ACID-5.4 ___ 11: 13PM HAPTOGLOB-<10* ___ 11: 13PM URINE HOURS-RANDOM CREAT-85 TOT PROT-970 PROT/CREA-11.4* ___ 11: 13PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG cocaine-NEG amphetmn-NEG oxycodn-NEG mthdone-NEG ___ 11: 13PM WBC-10.1* RBC-5.11 HGB-14.6 HCT-42.4 MCV-83 MCH-28.6 MCHC-34.4 RDW-13.7 RDWSD-41.0 ___ 11: 13PM PLT COUNT-133* ___ 11: 13PM URINE COLOR-Yellow APPEAR-Clear SP ___ ___ 11: 13PM URINE BLOOD-MOD* NITRITE-NEG PROTEIN-300* GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NORMAL PH-6.5 LEUK-NEG ___ 11: 13PM URINE RBC-2 WBC-2 BACTERIA-NONE YEAST-NONE EPI-1 ___ 11: 09PM ___ PTT-28.1 ___ ___ 11: 09PM ___ ___ 10: 40PM GLUCOSE-136* UREA N-14 CREAT-0.7 SODIUM-134* POTASSIUM-4.0 CHLORIDE-106 TOTAL CO2-19* ANION GAP-9* ___ 10: 40PM WBC-8.2 RBC-4.81 HGB-13.8 HCT-40.0 MCV-83 MCH-28.7 MCHC-34.5 RDW-13.7 RDWSD-41.6 ___ 10: 40PM NEUTS-73.1* ___ MONOS-6.9 EOS-0.0* BASOS-0.5 IM ___ AbsNeut-6.00 AbsLymp-1.56 AbsMono-0.57 AbsEos-0.00* AbsBaso-0.04 ___ 10: 40PM PLT COUNT-119* ___ 10: 40PM ___ PTT-27.8 ___ <MEDICATIONS ON ADMISSION> The Preadmission Medication list is accurate and complete. 1. Prenatal Vitamins 1 TAB PO DAILY <DISCHARGE MEDICATIONS> 1. Ibuprofen 200-600 mg PO Q6H: PRN Pain - Mild 2. NIFEdipine (Extended Release) 60 mg PO BID 3. Prenatal Vitamins 1 TAB PO DAILY <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> eclampsia posterior reversible leukoencephalopathy syndrome s/p cesarean section <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Call for headache, changes in your vision, shortness of breath, abdominal pain, increased swelling, or lightheadedness.
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Pt was transferred to L&D from ED. Soon after arrival she had a seizure c/w eclampsia. She was stabilized and an attempt was made to induce labor, but due to the FHR and remoteness from vaginal delivery she had a LTCS. Had magnesium sulfate for 24 hours Labs were c/w HELLP syndrome MRI/MRA/MRV was c/w PRES. Post-partum course notable for severe range blood pressure POD #3, ultimately controlled with nifedipine XR 60mg bid. During stay pt was seen by ___, Neuro, & ophthalmology. Opthalmology consult thought that her cx were all cortical, but did note possible early cupping of optic nerve and mild exophoria. At time of d/c BPs were well-controlled and pt had no residual neuro or visual sx. LFTs were mildly elevated. It was not clear if this was due to mild hepatic dysfunction or hemolysis. Renal function remained normal during her stay.
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11129757-DS-11
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Patient recorded as having No Known Allergies to Drugs <ATTENDING> ___ <CHIEF COMPLAINT> Scheduled surgery for likely primary peritoneal cancer <MAJOR SURGICAL OR INVASIVE PROCEDURE> Exploratory laparotomy Total abdominal hysterectomy Omenectomy Resection of mesenteric nodules Rectosigmoid resection with reanastomosis <HISTORY OF PRESENT ILLNESS> Ms. ___ is a ___ yo G1P1 with a h/o breast CA and BRCA-1 mutation s/p prophylactic BSO in ___ who was admitted to ___ service ___ for new pelvic mass and abdominal ascites. Pt was in her usual state of health until past week when she noted increased abdominal distention, nausea, early satiety. She had one similar episode of abdominal distention in ___ which resolved within one week. She presented to ___ ED on ___ and a CT scan of the abd/pelvis reveals a large amount of ascites. The liver, spleen, pancreas, and adrenals appeared normal. The left kidney had a 2cm cyst. There was no evidence of hydronephrosis. There was a cystic lesion noted in the pelvic posterior to the uterus on the right measuring 5.9 x 3.7 cm. The uterus was unremarkable. There were scattered lymph nodes in the omentum. Currently, she continues to have mild nausea and abdominal distention. She denies f/c, CP/SOB. Notes urinary frequency. Denies constipation. No recent changes in weight. <PAST MEDICAL HISTORY> ObHx: G1P1 -C-section GynHx: Surgical menopause in ___. No bleeding since that time. No h/o abnl paps. Colonoscopy ___ was normal. PMH: -Breast cancer diagnosed in ___. In ___ underwent L breast mass excision, L axillary diseection, XRT, no adjuvant tx. In ___, was diagnosed with recurrent L breast CA, infiltrating ductal CA. Underwent L breast mass excision initially then L total mastectomy, adjuvant cytoxan/adriamycin and taxol. -BRCA-1 carrier diagnosed in ___. -___ underwent LSC prophylactic BSO by Dr. ___ negative) -___ underwent prophylactic R mastectomy with subsequent breast reconstructive surgeries in ___ PSH: -as above <SOCIAL HISTORY> ___ <FAMILY HISTORY> ___ descent. Mother developed lung CA at age ___, was a smoker, did not have breast or ovarian cancer. Paternal grandmother with breast CA in ___ but lived until ___. Maternal grandmother with stomach cancer. Pt has a sister age ___ who has not had BRCA testing. Pt has a brother age ___ who is healthy. <PHYSICAL EXAM> 97.6/97.6, 140/70, 78, 18, 99%RA Appears comfortable CTA bilaterally RRR Soft, non-distended, NT. Dullness to percussion. Unable to perceive fluid wave SVE: Narrow vaginal introitus. Cervix barely palpable but no lesions. Exam limited by habitus, fullness appreciated in right adnexa. Mild tenderness to palpation bilateral adnexa. No ___ edema, NT <PERTINENT RESULTS> LABS: <MEDICATIONS ON ADMISSION> Motrin PRN <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. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation. Disp: *40 Capsule(s)* Refills: *0* 3. Oxycodone-Acetaminophen ___ mg Tablet Sig: ___ Tablets PO every ___ hours as needed for pain. Disp: *50 Tablet(s)* Refills: *0* <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> Primary peritoneal 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 ___ yo G1P1 with a h/o breast CA and BRCA-1 mutation s/p prophylactic BSO in ___ who was admitted to OMED service ___ for new pelvic mass and abdominal ascites, concerning for primary peritoneal cancer. She is now s/p exploratory laparotomy, total abdominal hysterectomy, omenectomy, resection of mesenteric nodules (done by GYN), and rectosigmoid resection with reanastomosis (done by GEN SURG) (see operative note for details). The patient's post-operative course was uneventful. Because of her primary bowel reanastomosis, she remained NPO with IV fluids until POD#4, at which time she passed flatus. Her diet was then slowly advanced as tolerated. She was able to tolerate a regular diet without difficulty by her day of discharge. Additionally, on POD#1, the patient was noted to have low urine output. She received a 500cc fluid bolus with an appropriate response in her urine output. The patient's urine output remained adequate for the remainder of her hospitalization. During this hospitalization, her pain was initially controlled with a Dilaudid PCA. Once the patient was able to tolerate PO, she was transitioned to PO Percocet and Motrin, with adequate pain control. She was able to ambulate and void without difficulty by her day of discharge. The patient was discharged home on POD#7 in stable condition.
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11131205-DS-9
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___ <CHIEF COMPLAINT> Vaginal bleeding, Fever <MAJOR SURGICAL OR INVASIVE PROCEDURE> Manual vacuum aspiration <HISTORY OF PRESENT ILLNESS> CC: pain, bleeding HPI: ___ yo G4P1 at ___ weeks who presents with vaginal bleeding and malaise. She had an early OB visit on ___ at which time TVUS showed: Single intrauterine gestational sac, with no embryo or yolk sac seen. Later that day she developed vaginal bleeding and cramping. On ___ she presented to ___ for rhogam given RH negative. Today she has felt overall unwell and sick. Her bleeding has picked up today and she is having more pain and passing large clots. She denies feeling lightheaded or dizzy. Denies dysuria or frequency or back pain. She had a low grade temp of 100.0 at home earlier this week. This was a desired pregnancy. <PAST MEDICAL HISTORY> OB: G4P1 - SVD x1 - SAB x1 - TAB x1 GYN: - Denies STIs - LMP: Not sure, ? ___, around 8 weeks per patient PMH: Denies PSH: Denies Meds: - PNV ALL: NKDA <SOCIAL HISTORY> ___ <FAMILY HISTORY> Noncontributory <PHYSICAL EXAM> INITIAL EXAM Exam: Vitals: 100.3 92 126/86 18 100% RA General: eyes closed, fatigued Resp: breathing comfortably Abd: soft, voluntary gurading, no rebound, mild lower middle abdominal tenderness, not an acute abdomen Pelvic: normal external genitalia, vaginal vault with 2 scopettes of blood, ~10 mL, no purulent discharge or products of conception, cervical oz partially open, no CMT, moderate uterine tenderness, exam limited due to discomfort and anxiety - DISCHARGE EXAM Vital signs: ___ ___ Temp: 98.5 PO BP: 100/58 HR: 71 RR: 16 O2 sat: 100% O2 delivery: RA ___ 0005 Temp: 98.8 PO BP: 98/68 HR: 80 RR: 16 O2 sat: 99% O2 delivery: RA General: NAD, comfortable CV: RRR Lungs: normal work of breathing, CTAB Abdomen: soft, non-distended, mild fundal tenderness, no rebound/guarding GU: pad with minimal spotting Extremities: no edema, no TTP, pneumoboots in place bilaterally <PERTINENT RESULTS> ___ 12: 12AM BLOOD WBC-20.1* RBC-3.75* Hgb-11.6 Hct-35.2 MCV-94 MCH-30.9 MCHC-33.0 RDW-12.3 RDWSD-42.5 Plt ___ ___ 12: 12AM BLOOD Neuts-81.4* Lymphs-11.6* Monos-5.6 Eos-0.7* Baso-0.1 Im ___ AbsNeut-16.41* AbsLymp-2.33 AbsMono-1.12* AbsEos-0.14 AbsBaso-0.02 ___ 01: 05PM BLOOD WBC-22.5* RBC-3.46* Hgb-10.9* Hct-32.0* MCV-93 MCH-31.5 MCHC-34.1 RDW-12.2 RDWSD-41.1 Plt ___ ___ 01: 05PM BLOOD Neuts-83.4* Lymphs-10.4* Monos-5.2 Eos-0.2* Baso-0.2 Im ___ AbsNeut-18.77* AbsLymp-2.33 AbsMono-1.17* AbsEos-0.05 AbsBaso-0.04 ___ 06: 40AM BLOOD WBC-9.5 RBC-3.28* Hgb-10.2* Hct-31.0* MCV-95 MCH-31.1 MCHC-32.9 RDW-12.2 RDWSD-42.5 Plt ___ ___ 07: 10AM BLOOD Neuts-38.5 ___ Monos-13.6* Eos-4.6 Baso-0.2 Im ___ AbsNeut-1.93 AbsLymp-2.14 AbsMono-0.68 AbsEos-0.23 AbsBaso-0.01 ___ 07: 10AM BLOOD WBC-5.0 RBC-3.30* Hgb-10.2* Hct-31.3* MCV-95 MCH-30.9 MCHC-32.6 RDW-12.4 RDWSD-43.6 Plt ___ ___ 12: 12AM BLOOD Glucose-95 UreaN-12 Creat-0.6 Na-140 K-4.0 Cl-103 HCO3-24 AnGap-13 ___ 12: 12AM BLOOD ALT-19 AST-18 AlkPhos-78 TotBili-0.4 ___ 12: 12AM BLOOD Albumin-3.9 Calcium-8.9 Phos-3.0 Mg-1.5* ___ 12: 12AM BLOOD ___ ___ 02: 27AM BLOOD Lactate-0.82 <MEDICATIONS ON ADMISSION> PNV <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 #*27 Tablet Refills: *0 2. Doxycycline Hyclate 100 mg PO Q12H RX *doxycycline hyclate 100 mg 1 capsule(s) by mouth twice a day Disp #*27 Capsule Refills: *0 3. Ondansetron ODT 4 mg PO Q8H: PRN Nausea/Vomiting - First Line RX *ondansetron 4 mg 1 tablet(s) by mouth every eight (8) hours Disp #*42 Tablet Refills: *0 <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> Septic abortion <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 take more than 4000mg acetaminophen (APAP) in 24 hrs. * No strenuous activity until your post-op appointment. * Nothing in the vagina (no tampons, no douching, no sex) for 2 weeks. * You may eat a regular diet. * You may walk up and down stairs. Call your doctor for: * fever > 100.4F * severe abdominal pain * difficulty urinating * vaginal bleeding requiring >1 pad/hr * abnormal vaginal discharge * nausea/vomiting where you are unable to keep down fluids/food or your medication To reach medical records to get the records from this
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On ___, Ms. ___ was admitted to the gynecology service after undergoing a manual vacuum aspiration for a septic abortion. Her hospital course is summarized by problem below: *) Septic abortion: At initial presentation, she was febrile with a Tmax of 102.3 on ___. Her labs were notable for a significant leukocytosis which peaked at 22.5 on ___. She underwent a bedside manual vacuum aspiration by GYN while still in the ED and tolerated the procedure well. A bedside transabdominal ultrasound after the procedure showed a thin endometrial stripe without evidence of retained products of conception. Given her Rh negative blood type, she was administered Rhogam. She was empirically treated with IV ampicillin/gentamicin/clindamycin (___) for presumed septic abortion. On ___, she was transitioned to PO doxycycline/Augmentin to complete a 14 day antibiotic course. Her leukocytosis resolved with a WBC of 5.0 on ___. Her BCx were negative. *) Possible UTI: Her initial UA was notable for large blood and leukocytes with negative nitrites. Given her equivocal UA and lack of dysuria, treatment was deferred pending the results of her UCx. Her UCx grew >100,000 CFUs of Group A Strep. She was started on PO Augmentin/Doxycycline for coverage of Group A strep UTI vs septic abortion as etiology of fever. She had clinically improved and had remained afebrile for 48 hours on hospital day 3 and was discharged home on PO antibiotics with outpatient follow up scheduled.
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11132745-DS-22
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Paxil / Zoloft <ATTENDING> ___ <CHIEF COMPLAINT> Microinvasive cervical CA Vaginal dysplasia <MAJOR SURGICAL OR INVASIVE PROCEDURE> Total laparoscopic hysterectomy Right salpingectomy Upper vaginectomy Cystoscopy Colposcopy <HISTORY OF PRESENT ILLNESS> ___ is a ___ gravida 5, para 5 woman who has a long history of abnormal Pap smears. As a young woman, prior to having children, she was told that she had a "class 3" Pap smear and she has undergone in the past laser, loop, and cold knife cone excisions of the cervix. Her most recent excision was performed on ___. A posterior lip excision revealed CIN 3 involving endocervical glands focally extending to the inked specimen margin. The anterior lip specimen revealed CIN 3 involving endocervical glands and focally extending to the inked margin. An endocervical excision revealed CIN 3 involving the endocervical gland with a small focus suspicious for superficial invasion. An endocervical curettage was performed on ___. This revealed low-grade SIL. She is here for discussion of treatment options. Ms. ___ denies any history of immune modulating disease or disorder. She takes no prednisone and has no diagnosis of HIV or autoimmune disease. <PAST MEDICAL HISTORY> PAST MEDICAL HISTORY: She denies any history of asthma, hypertension, mitral valve prolapse, or thromboembolic disorder. She has never had a mammogram nor has she had a colonoscopy. PAST SURGICAL HISTORY: She underwent a laparoscopic cholecystectomy. OB/GYN HISTORY: She reports the abnormal Pap smears noted above. She has no history of fibroids or ovarian cysts. <SOCIAL HISTORY> ___ <FAMILY HISTORY> She reports grandmother, an aunt, and a cousin had cancers. She reports that her aunt may have had ? ovarian cancer at the age of ___, a cousin may have had ovarian cancer at the age of ___, and a grandmother may have had ovarian cancer at the age of ___. With this said, questioning about this family history, which is pretty significant reveals that it is really not clear that this patient knows very much about the diseases that her relatives have had. She reports also that she is not in a position to find out more about her family history. <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 thyromegaly. LYMPHATICS: Lymph node survey, negative cervical, supraclavicular, axillary, or inguinal adenopathy appreciated. LUNGS: Clear bilaterally. HEART: Regular rate and rhythm. There are no appreciable murmurs. BACK: No spinal or CVA tenderness. ABDOMEN: Soft, nontender, nondistended. There are no palpable masses. There is no hepatomegaly or splenomegaly. There is no fluid wave. EXTREMITIES: There is no clubbing, cyanosis, or edema. There is no calf tenderness to palpation. PELVIC: Reveals normal external genitalia. There is no condylomatous change. The inner labia minora is normal. The urethral meatus is normal. A speculum is placed. The walls of the vagina are smooth. At the apex of the vaginal canal, there is a slight irregularity to the perivaginal tissue on the right side. This appears to be acetic white to application. The cervix itself shows evidence of prior LEEP excision, but is well formed and protrudes from the apex of the vaginal canal. In short, there is good cervical length. Bimanual exam reveals an anteverted uterus. There is no palpable mass. There is good parametrial tissue present, but there is no nodularity or irregularity. There is good descensus. There is no palpable mass. The uterus is normal in size and mobility. There is no adnexal mass. RECTAL: Reveals no mass or lesion. <PERTINENT RESULTS> None <MEDICATIONS ON ADMISSION> Wellbutrin, BuSpar, Clonidine, Motrin, Ativan, vitamin C, Benadryl, vitamin D, flaxseed oil, one a day. <DISCHARGE MEDICATIONS> 1. Oxycodone-Acetaminophen ___ mg Tablet Sig: One (1) Tablet 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: *45 Tablet(s)* Refills: *0* 3. Buspirone 5 mg Tablet Sig: Three (3) Tablet PO TID (3 times a day). 4. Clonidine 0.1 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 5. Bupropion 100 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 6. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed. 7. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day as needed for constipation. Disp: *30 Capsule(s)* Refills: *0* <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> Microinvasive cervical CA Vaginal dysplasia <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 ___ G5P5 female with microinvasive cervical cancer and vaginal dysplasia, now s/p total laparoscopic hysterectomy, right salpingectomy, upper vaginectomy, cystoscopy, and colposcopy (see operative note for details). The patient's post-operative course was complicated by anxiety. The patient remained on her home psych medications. She was followed by social work throughout her hospitalization. Her pain remained well controlled throughout her hospitalization. She was able to tolerate a regular diet, ambulate, and void without difficulty on her day of discharge. The patient was discharged home on POD#2 in stable condition.
| 1,439
| 135
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11132790-DS-14
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___ <CHIEF COMPLAINT> presents for the below scheduled procedures. <MAJOR SURGICAL OR INVASIVE PROCEDURE> colpocleisis, perineorrhaphy, cystoscopy <HISTORY OF PRESENT ILLNESS> Mrs. ___ is a ___ yo Gravida 6 ___ ___ who presented for a consultation requested by Dr. ___ vaginal prolapse. She is in fact complaining of pressure symptoms leading to problems with defecation. Her symptoms have been present for approximately ___ year. She has tried managing her symptoms with pessaries which were expelled shortly after insertion. She reports no incontinence events. She voids ___ times per day and ___ times per night. She uses no pads per day. She denies any urgency, she denies any dysuria and reports bladder emptying with normal flow. She denies any hematuria, UTI's, kidney stones or pyelonephritis. She also denies any constipation. She is not sexually active and does not experience dyspareunia. She admits to vaginal dryness. She is otherwise without any other significant complaints. She has had time to think about her options and elects to proceed with surgical management. There has been no interval changes in her symptoms or medical history. She has agreed to undergo: a ___ Colpocleisis, perineorrhaphy and cystoscopy. All questions regarding surgery, risks and benefits, possible complications reviewed. All consents signed. <PAST MEDICAL HISTORY> PAST MEDICAL HISTORY: 1. HTN 2. Hypercholesterolemia 3. Macular degeneration 4. PAST SURGICAL HISTORY 1. Appendectomy 2. Hysterectomy ? BSO PAST OB HISTORY G6P___ Vaginal: 5 <FAMILY HISTORY> Her family history is significant for a history of Breast Cancer in her mother and maternal GM and is otherwise unremarkable for Ovarian or Colon cancer. <PHYSICAL EXAM> Pre-operative examination Neuro/Psych: Oriented x3, Affect Normal, NAD. Neck: No masses, Trachea midline, Thyroid normal size, non-tender, no masses or nodules. Nodes: No clavicular/cervical adenopathy, No inguinal adenopathy. Skin: No atypical lesions. Heart: Normal sounds, no murmurs Lungs: Normal respiratory effort. Abdomen: Non tender, Non distended, No masses, guarding or rebound, No hepatosplenomegally, No hernia. Ext: No edema or varicosities. Vulva: Nl hair pattern, no lesions. Bus: Urethra NT, no masses, skin & bartholin glands normal, Urethra meatus central, no prolapse. Vagina: Ulceration on the right apex, Bladder non-tender, no masses appreciated. [See POP-Q] Cervix: Absent Uterus: Absent Adnexa: no masses non tender. POP-Q Exam: Aa: +3 Ba: +6 TVL: 8 D: N/A C: +6 ___: 5 PB: 2.5 Ap: +3 Bp: +6 ___ Exam: Complete eversion ulceration at right apex <PERTINENT RESULTS> No laboratory studies were required during this admission. <MEDICATIONS ON ADMISSION> Medications - Prescription ATORVASTATIN [LIPITOR] - (Prescribed by Other Provider) - 10 mg Tablet - Tablet(s) by mouth once a day ESTRADIOL [ESTRACE] - 0.01 % Cream - 1 gram per vagina at bedtime three times weekly ( 3 times a week) NIFEDIPINE - 60 mg Tablet Extended Rel 24 hr - 1 Tablet(s) by mouth once a day - No Substitution Medications - OTC CALCIUM - (Prescribed by Other Provider) - Dosage uncertain COD LIVER OIL - (Prescribed by Other Provider) - Dosage uncertain VIT C-VIT E-COPPER-ZNOX-LUTEIN [PRESERVISION] - (Prescribed by Other Provider) - Dosage uncertain <DISCHARGE MEDICATIONS> 1. oxycodone-acetaminophen ___ mg Tablet Sig: ___ Tablets PO Q4H (every 4 hours) as needed for pain. Disp: *40 Tablet(s)* Refills: *0* 2. nifedipine 60 mg Tablet Extended Release Sig: One (1) Tablet Extended Release PO DAILY (Daily). 3. atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Motrin 400 mg Tablet Sig: One (1) Tablet PO every six (6) hours. Disp: *60 Tablet(s)* Refills: *1* 5. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp: *60 Capsule(s)* Refills: *2* <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> vaginal prolapse <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> No heavy lifting x 6 weeks Nothing in your vagina You may shower, do not take a bath/ swim in a pool for the next 6 weeks. Regular diet. you may take percocet and motrin as prescribed for pain Do not drive while taking percocet. Call for: - fevers (>100.4), chills - foul smelling vaginal discharge - increased vaginal bleeding - increased pain not controlled by the medications prescribed to you
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Ms ___ underwent an uncomplicated colpocleisis, perineorrhaphy, cystoscopy; see operative report for details. She had an uncomplicated recovery and was discharged home on postoperative day #1 in good condition: ambulating and urinating without difficulty, tolerating a regular diet, and with adequate pain control using PO medication.
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| 72
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11133772-DS-3
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> amoxicillin / Penicillins / Bactrim / sulfathiazole / lithium <ATTENDING> ___. <CHIEF COMPLAINT> NICU proximity <MAJOR SURGICAL OR INVASIVE PROCEDURE> None at ___ <HISTORY OF PRESENT ILLNESS> Ms. ___ is a ___ G1P1 now ___ s/p pLTCS for NRFHT and arrest of dilation at 7cm, who was transferred from ___ for NICU proximity for evaluation of neonatal seizures. She also has a h/o IVDU and HepC, as well as gestational thrombocytopenia. She is also noted to have a complex psychosocial history, including unstable housing situation (currently living in a shelter), h/o PTSD from multiple physical, verbal, and sexual abuse encounters, including DV by FOB (not involved in pregnancy) and bipolar disorder. She presented in labor at 40w5d, was augmented with Pitocin and was ultimately recommended for a cesarean delivery given NRFHT and arrest of dilation. Apgars were 6,9. Per operative note, delivery was complicated by a difficult extraction, with R lateral extension down to the cervix and L lateral extension proximal to the uterine artery. For her history of IVDU, she has been clean throughout this pregnancy, with most recent negative Utox on ___. She was not on methadone or suboxone. She has been followed by ID and hepatology for her HepC, most recent VL at 66,000 in ___ with normal LFTs. She had negative HIV testing. She was noted to have gestational thrombocytopenia beginning approximately one month ago, with most recent plt at 83 (___). She has otherwise had normal BPs and normal testing this pregnancy. <PAST MEDICAL HISTORY> OBHx: G1 - as above GYNHx: denies h/o STIs, h/o abnl pap smears, or GYN surgeries MedHx: - Chronic HepC - Migraines - PTSD - h/o IVDU - Anemia - Bipolar Disorder SurgHx: C/S as above <SOCIAL HISTORY> ___ <FAMILY HISTORY> non contributory <PHYSICAL EXAM> Physical Exam on Discharge: VS: Afebrile, VSS Neuro/Psych: NAD, Oriented x3, Affect Normal Lungs: breathing comfortably on room air Abdomen: soft, appropriately tender, fundus firm Pelvis: minimal bleeding Extremities: warm and well perfused, no calf tenderness, no edema <PERTINENT RESULTS> ___ 09: 40PM BLOOD WBC-10.8*# RBC-2.97*# Hgb-8.7*# Hct-25.9*# MCV-87 MCH-29.3 MCHC-33.6 RDW-13.7 RDWSD-43.5 Plt ___ ___ 09: 40PM BLOOD ___ PTT-27.1 ___ ___ 09: 40PM BLOOD ALT-19 AST-27 <MEDICATIONS ON ADMISSION> prenatal vitamins, tums <DISCHARGE MEDICATIONS> 1. Acetaminophen ___ mg PO Q6H: PRN Mild Pain RX *acetaminophen 500 mg ___ tablet(s) by mouth every 6 hours Disp #*20 Tablet Refills: *0 2. Docusate Sodium 100 mg PO BID: PRN Constipation RX *docusate sodium 100 mg 1 capsule(s) by mouth twice daily Disp #*20 Capsule Refills: *0 3. Ferrous Sulfate 325 mg PO DAILY anemia RX *ferrous sulfate 325 mg (65 mg iron) 1 tablet(s) by mouth daily Disp #*30 Tablet Refills: *0 4. Ibuprofen 600 mg PO Q6H: PRN Moderate Pain RX *ibuprofen 600 mg 1 tablet(s) by mouth every 6 hours Disp #*20 Tablet Refills: *0 5. OxyCODONE (Immediate Release) ___ mg PO Q4H: PRN Pain - Moderate Reason for PRN duplicate override: Alternating agents for similar severity RX *oxycodone 5 mg ___ tablet(s) by mouth every ___ hours Disp #*20 Tablet Refills: *0 <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> postpartum transfer for NICU proximity S/p c-section at ___ <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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Ms. ___ is a ___ G1P1 who underwent pLTCS for NRFHT and arrest of dilation on ___, with a medical history notable for hepatitis C, IV drug use, gestational thrombocytopenia, and multiple social stressors. She was transferred to ___ from ___ for NICU proximity. Her intrapartum and post partum course were as follows: *) History of IV drug use: Ms. ___ had a negative urine toxin screen on ___. *) Vulvar edema and lower extremity edema: Post partum, Ms. ___ was noted to have vulvar and lower extremity edema, thought to likely be from fluid shifts associated with pregnancy. There was no evidence of infection or blood clots. She did receive one dose of Lasix 20 mg PO on ___. *) Chronic Hepatitis C Ms. ___ is followed by infectious disease at ___ ___. Her last viral load was 66,000 (___). She has normal LFTs and is HIV negative. *) Gestational thrombocytopenia Platelets were 83 on ___, and 101 on admission. Bleeding was normal. *) Social stressors Ms. ___ was followed by social work for her history of unstable housing and history of domestic abuse by father of the baby. By postpartum day 4, she was tolerating a regular diet, ambulating independently, and pain was controlled with oral medications. She was afebrile with stable vital signs. She was then discharged home in stable condition with postpartum outpatient follow-up scheduled.
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11136043-DS-21
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> menorrhagia and dysmenorrhea <MAJOR SURGICAL OR INVASIVE PROCEDURE> total laparoscopic hysterectomy, bilateral salpingectomy, lysis of adhesions <HISTORY OF PRESENT ILLNESS> The patient is a ___, gravida 2, para 2, with a history of 2 prior cesarean deliveries, who has a long history of menorrhagia and dysmenorrhea. She had been controlled on oral contraceptive pills for many years. She underwent a NovaSure ablation approximately ___ years ago for persistent menorrhagia. For the ___ ___ years she had little to no vaginal bleeding, but then her periods returned. Her periods are now persistently heavy and she has a worsening pelvic pain, which is severe and debilitating. She underwent a pelvic ultrasound, which revealed a somewhat enlarged uterus, approximately 9 x 4 x 4.5 cm. There was no adnexal pathology. She underwent an endometrial biopsy, which was benign. She underwent a Pap smear, which was negative. She was counseled on her options for management. She desired definitive surgical therapy by hysterectomy. It was recommended that she undergo a total laparoscopic hysterectomy given her prior cesarean deliveries. It was also decided that at the time of surgery, she was undergo bilateral salpingectomy for ovarian cancer risk reduction. Her ovaries were to remain in situ given her premenopausal status. <PAST MEDICAL HISTORY> PMH: none PSH: Endometrial ablation, c/s x 2, LSC CCY POBGynhx: G2P2, C/S x 2, menorrhagia, not sexually active <SOCIAL HISTORY> ___ <FAMILY HISTORY> non-contributory <PHYSICAL EXAM> Presenting Exam BP 138/90 | Ht 5' 7" (1.702 m) | Wt 232 lb 3.2 oz (105.325 kg) | BMI 36.36 kg/m2 | LMP ___ General Appearance: well appearing and overweight Resp: normal effort, no accessory muscle use ___ pulses 2+ Abdomen: no tenderness and no masses. Prior ___ scar present. Lymph nodes: no inguinal adenopathy Pelvic deferred today but from last week: External Genitalia: no lesions or inflammation Vagina: no lesions Pelvic Supports: uterine descensus minimal, likely due to scarring from prior c/s's Cervix: no lesions, no cervical motion tenderness. Uterus: normal size, non-tender, smooth contour and anteverted Adnexa: no palpable mass, no tenderness Anus and Perineum: normal Ext: no edema Neuro: AAO x 3, mood and affect appropriate Discharge Exam Vital signs stable Well appearing, no acute distress Abdomen soft, nondistended Incisions clean, dry, intact <PERTINENT RESULTS> Intraoperative Findings: 1. Exam under anesthesia was limited by body habitus, but overall, revealed a small, mobile, anteverted uterus. There were no adnexal masses palpated. 2. Laparoscopic survey revealed a normal upper abdominal survey. There were extremely dense omental and small bowel adhesions to the anterior abdominal wall at the site of her prior ___ incision. This required lysis of adhesions for 1 hour by Gynecologic Surgery, and then for approximately an hour and a half by General Surgery. Pelvic evaluation revealed a moderately- enlarged uterus. The bladder was densely adherent to the anterior uterus at the level of the round ligaments. The fallopian tubes and ovaries were grossly normal bilaterally. <MEDICATIONS ON ADMISSION> oral contraceptive pills <DISCHARGE MEDICATIONS> 1. Acetaminophen ___ mg PO Q6H: PRN pain Max 4000 mg in 24 hours 2. Docusate Sodium 100 mg PO BID 3. Ibuprofen 600 mg PO Q6H: PRN Pain Take with food. 4. OxycoDONE (Immediate Release) ___ mg PO Q4H: PRN pain Do not drive while taking. <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> pelvic pain, menorrhagia <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Dear Ms. ___, You were admitted to the gynecology service after your procedure. You have recovered well and the team believes you are ready to be discharged home. Please call Dr. ___ office with any questions or concerns. Please follow the instructions below. General instructions: * Take your medications as prescribed. * Do not drive while taking narcotics. * Take a stool softener such as colace while taking narcotics to prevent constipation. * Do not combine narcotic and sedative medications or alcohol. * Do not take more than 4000mg acetaminophen (APAP) in 24 hrs. * No strenuous activity until your post-op appointment. * Nothing in the vagina (no tampons, no douching, no sex) for 3 months. * No heavy lifting of objects >10 lbs for 6 weeks. * You may eat a regular diet. * You may walk up and down stairs. Incision care: * You may shower and allow soapy water to run over incision; no scrubbing of incision. No bath tubs for 6 weeks. * If you have steri-strips, leave them on. They will fall off on their own or be removed during your followup visit. Call your doctor for: * fever > 100.4 * severe abdominal pain * difficulty urinating * vaginal bleeding requiring >1 pad/hr * abnormal vaginal discharge * redness or drainage from incision * nausea/vomiting where you are unable to keep down fluids/food or your medication To reach medical records to get the records from this hospitalization sent to your doctor at home, call ___.
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On ___, Ms. ___ was admitted to the gynecology service after undergoing total laparoscopic hysterectomy, bilateral salpingectomy, lysis of adhesions. 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 oxycodone, tylenol, and motrin. Later that 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.
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11137560-DS-17
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___ <CHIEF COMPLAINT> Pelvic mass <MAJOR SURGICAL OR INVASIVE PROCEDURE> Exploratory laparoscopy Exploratory laparotomy lysis of adhesions radical resection of abdominopelvic tumor bilateral salpingo-oophorectomy total abdominal hysterectomy infracolic omentectomy resection pelvic sidewall tumor appendectomy cystoscopy optimal cytoreduction <HISTORY OF PRESENT ILLNESS> Ms. ___ is a ___ gravida 2, para 2 woman who was noted on a pelvic exam to have a large pelvic mass at her annual gyn visit. An ultrasound performed on ___ revealed a 17 x 11 x 17 cm mass, which appeared to be composed of both ovaries. The right adnexal mass measured 12 x 9 x 10 cm and the left adnexal mass measured 8.9 x 7 cm. Minimal vascularity was identified within the mass and there was no evidence of free fluid or peritoneal carcinomatosis. She had no symptoms of these pelvic masses and is otherwise in relatively good health. She denied any history of endometriosis or cancer herself. She reported that her mother had breast cancer in her ___ and an aunt may have had ovarian cancer as a younger woman. <PAST MEDICAL HISTORY> No significant past medical history <SOCIAL HISTORY> ___ <FAMILY HISTORY> She reports her mother had breast cancer at the age of ___ ___s a maternal great aunt. A grandmother may have had ovarian cancer <PHYSICAL EXAM> General: comfortable, well appearing woman HEENT: mucus membranes moist CV: regular rate and rhythm Pulm: clear to auscultation bilaterally Abd: soft, appropriately tender, positive bowel sounds throughout incisions are clean dry and intact Extremities: non tender, non edematous <PERTINENT RESULTS> ___ ___ <MEDICATIONS ON ADMISSION> The Preadmission Medication list may be inaccurate and requires futher investigation. 1. Aspirin 81 mg PO DAILY <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 #*100 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 #*100 Tablet Refills: *1 3. Oxycodone-Acetaminophen (5mg-325mg) ___ TAB PO Q4H: PRN pain RX *oxycodone-acetaminophen 5 mg-325 mg ___ tablet(s) by mouth every four (4) hours Disp #*60 Tablet Refills: *0 4. Aspirin 81 mg PO DAILY <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> ovarian cancer, pending final pathology <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Dear ___ were admitted to the gynecologic oncology service after undergoing the procedures listed below. ___ have recovered well after your operation, and the team feels that ___ are safe to be discharged home. Please follow these instructions: * Take your medications as prescribed. * Do not drive while taking narcotics. * Do not combine narcotic and sedative medications or alcohol * Do not take more than 4000mg acetaminophen (APAP) in 24 hrs * No strenuous activity until your post-op appointment * Nothing in the vagina (no tampons, no douching, no sex) for 12 weeks. * No heavy lifting of objects >10 lbs for 6 weeks. * ___ may eat a regular diet . Incision care: * ___ may shower and allow soapy water to run over incision; no scrubbing of incision. No bath tubs for 6 weeks. * ___ 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 laparascopic converted to exploratory laparotomy, lysis of adhesions, radical resection of abdominopelvic tumor, bilateral salpingo-oophorectomy, total abdominal hysterectomy, infracolic omentectomy, resection pelvic sidewall tumor, appendectomy, cystoscopy, and optimal cytoreduction. Please see the operative report for full details. On Post-operative day #1 her blood pressure decreased to 68/54 while sitting. She was hemodynamically stable, had adequate urine output and was found to have a hematocrit of 31.7. Her blood pressure remained stable for the remainer of the hospital stay. On post-operative day #2 her foley catheter was removed and she voided spontaneously. She was tolerating a regular diet, ambulating independently, and pain was controlled with oral medications. She was then discharged home in stable condition with outpatient follow-up scheduled.
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11137560-DS-19
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> carboplatin <ATTENDING> ___ <CHIEF COMPLAINT> small bowel obstruction <MAJOR SURGICAL OR INVASIVE PROCEDURE> none <HISTORY OF PRESENT ILLNESS> Ms. ___ is a ___ female G2P2 with a history of recurrent stage IIIB ovarian cancer originally diagnosed in ___ and reoccurrence in ___ s/p ex-lap TAH-BSO debulk in ___, currently on chemotherapy, previously on weekly Taxol but recently transitioned to Faslodex on ___, who presents as a transfer from ___ for a small bowel obstruction. She reported that on ___ she began to develop crampy and periumbilical pain consistent with her usual small bowel obstructions. She also endorses ___ episodes of emesis at this time. She notes significant worsening of the abdominal pain on ___. She describes this pain as more in the epigastric region and exacerbated by movement. On ___ pain reached maximum severity prompting her presentation on ___ to the outside hospital. She states that throughout this entire time she has continued to have bowel movements and flatus. Exam at the outside hospital was notable for normal vital signs, soft non-distended abdomen. She was seen by general surgery and evaluated and felt that there was no need for surgical intervention and recommended management of small bowel obstruction conservatively. Labs the outside hospital were notable for a mild leukopenia 3.1, hematocrit of 35.4, normal electrolytes with the exception of a magnesium of 0.66. CT abdomen and pelvis was done which showed chronic versus recurrent small bowel obstructions with 2 transitional points seen along the undersurface of the anterior abdominal wall. The first transition zone appears to be in the anterior abdomen slightly above the level of the umbilicus with multiple mildly to moderately distended nonopacified small bowel loops present in the pelvis. There also appears to be a second transition zone underlying the anterior abdominal wall where there does appear to be some tenting of the mesentery suggestive of the presence of adhesions. There is fluid in the ascending colon. The transverse and descending colon are not distended. There is no free air. Scattered calcified metastatic masses display no interval enlargement. No new mesenteric, periaortic, iliac chain, or inguinal lymphadenopathy are seen. Chronic calcified inguinal nodes are stable. She was admitted to the med/surge service, initially made n.p.o., and managed conservatively with pain control and bowel rest. Her diet was slowly advanced from clear liquids to full liquids. Each time she attempted to advance her diet there would be significant increase in her abdominal pain. She last ate on ___ (the day of presentation) some broth and ice cream which resulted in significant increase of her abdominal pain. She denies any episodes of emesis. She denies any fevers or chills, nausea or vomiting, constipation or diarrhea, dysuria or hematuria, abnormal vaginal bleeding or unusual vaginal discharge. Of note, the patient has a history of multiple small bowel obstructions. She had 4 in the course of the past 6 months all medically managed. She first presented on ___ to ___ ___. The obstruction was medically managed and an NGT was placed. She has had several additional episodes are medically managed. The most recent prior to this presentation she managed at home she made herself n.p.o. and drink clear liquids and the obstruction subsequently resolved. She continues on a low residual diet. ROS: 10-system review negative except as noted in the HPI <PAST MEDICAL HISTORY> Oncology History: - ___: Noted to have a large pelvic mass on Gyn annual visit. An ultrasound on ___ revealed a 17 x 11 x 17 cm mass, which appeared to be composed of both ovaries. The right adnexal mass measured 12 x 9 x 10 cm and the left adnexal mass measured 8.9 x 7 cm. Minimal vascularity was identified within the mass and there was no evidence of free fluid or peritoneal carcinomatosis. Her CA-125 on ___ was 72. - ___: CT scan of the chest, abdomen and pelvis revealed findings strongly suspicious for malignant ovarian neoplasm with bilateral involvement. There was no evidence of extrapelvic disease. - ___: She underwent an exploratory laparoscopy, exploratory laparotomy, lysis of adhesions, and radical resection of abdominopelvic tumor, bilateral salpingo-oophorectomy, total abdominal hysterectomy, and infracolic omentectomy, resection of pelvic sidewall tumor, appendectomy, and cystoscopy. On completion of surgery she was completely staged and optimally cytoreduced. Final pathology showed grade 1 well differentiated ovarian papillary serous carcinoma on bilateral ovaries and fallopian tubes. Metastatic serous carcinoma was identified on the peritoneum, omentum, right paracolic gutter and appendix. Diagnosed with stage IIIB cytoreduced ovarian cancer. - ___ C1D1 IV ___ - ___: Negative BRCA1/BRCA2. - ___: 5 cycles of IP cisplatin/taxol - ___ - ___: Hospital admission for Afib, febrile neutropenia - ___ CT chest showed no evidence of intrathoracic metastatic disease. CT A/P showed enhancing 1.6 cm soft tissue nodule superior to the dome of the bladder. Enhancing right iliac lymph node measuring 7 mm and 6 mm perirectal lymph node. Minimal studding of the omentum without definitive soft tissue nodules. These findings raise the suspicion of recurrence. Soft tissue density along the lateral portions of the vaginal cuff may be related to postsurgical changes or recurrence of disease. Recommend pelvic MRI or PET for further evaluation. Unchanged appearance of left adrenal nodule and multiple liver hypodensities, consistent with cysts, as compared to prior study from ___. - ___: Started on Anastrazol due to CA-125 rise to 41 (steadily increased from nadir of 8.9 ___. - ___ start weekly Taxol 60mg/m2 and Carboplatin auc ___ - ___ added neupogen 300mg x 3 days support to regimen - ___ completed 6 cycles weekly Taxol/Carboplatin. CT scan showed treatment response. - ___ start of treatment break - ___ restart weekly Taxol/Carboplatin- mild reaction- nasal congestion, palmar itching at end of Carboplatin infusion - ___ continue weekly Taxol 60mg/m2, added Bevacizumab 10mg/kg on D1 and D15 - ___ CT Scan: No evidence of intrathoracic metastatic disease. Minimally increased right axillary lymph nodes. Interval decrease in size of multiple omental and pelvic implants and improvement in pelvic LAD suggests response to treatment. Stable, prominent, bilateral inguinal LNs. Soft tissue density along the right lateral portion. CA 125, ___ 29. - ___ SBO- admitted to ___ - ___ CA125 down to 34 from 43; CT AP shows treatment response; CT chest with minimal bilateral pleural effusions may reflect pleural fluid, however small pleural tumor implants cannot be ruled out. - ___ resumed Taxol alone - ___ SBO- admitted to ___ - ___ SBO- admitted to ___- Taxol held on ___ and ___ - ___ resume Taxol - ___ CT showed disease progression. Increased omental nodularity and increase in size of soft tissue peritoneal nodule adjacent to the sigmoid colon. - ___ Stop Taxol- start Faslodex <PAST MEDICAL HISTORY> recurrent stage IIIB ovarian cancer as above, anxiety. Denies history of asthma, diabetes, heart disease. Past Surgical History: right knee arthroscopy ___, hammertoe surgery at ___ ___ Ob/Gyn History: She is a G2P2. She reports SVDs in ___ and ___ without complications. She is post-menopausal, LMP in ___. Last Pap in ___, which was normal, and denies history of abnormal Pap smears. She does report a history of chlamydia, but otherwise has had no pelvic infections. Denies history of OCPs or HRT. <SOCIAL HISTORY> ___ <FAMILY HISTORY> She reports her mother had breast cancer at the age of ___ ___s a maternal great aunt. She had a grandmother w/ ovarian cancer. The patient reports that she is of ___ and ___ ancestry. <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 ___: nontender, nonedematous <MEDICATIONS ON ADMISSION> lorazepam 1mg QHS, docusate 100mg daily <DISCHARGE MEDICATIONS> lorazepam 1mg QHS, docusate 100mg daily <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> small bowel obstruction <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Dear Ms. ___, . You were admitted to the gynecologic oncology service from ___ for management of a small bowel obstruction. You have recovered well and the team feels that you are safe to be discharged home. Please follow these instructions: . Diet * Please maintain a low residue diet, and eat small meals. . 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 transfer from ___ for management of small bowel obstruction. She was made NPO and placed on IV fluids and given IV zofran for nausea and IV acetaminophen for pain control. She was given Lovenox for DVT prophylaxis. Re-read of her outside CT scan from ___ showed: 1. Recurrent Small bowel obstruction with ___istant from each other are concerning for adhesions. 2. Stable left inguinal and right pelvic lymphadenopathy, peritoneal implant on the sigmoid colon an omental nodules concerning for metastatic disease. No new lesions seen. 3. Stable liver cysts or biliary hamartomas 4. Stable indeterminate left adrenal lesion likely representing an adenoma On hospital day #1 she was advanced to sips and then to clears later in the day. She tolerated this without abdominal pain, nausea or vomiting. Her diet was slowly advanced during her admission, and she required minimal acetaminophen for control of her abdominal pain. By hospital day #4, she was tolerating a regular diet, without nausea, vomiting or abdominal pain. She was then discharged home in stable condition with outpatient follow-up scheduled.
| 2,138
| 255
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11137560-DS-20
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> carboplatin <ATTENDING> ___ ___ Complaint: abdominal pain, nausea, vomiting <MAJOR SURGICAL OR INVASIVE PROCEDURE> exploratory laparotomy, lysis of adhesions, small bowel resection and anastomosis, bladder oversew, and cystoscopy <HISTORY OF PRESENT ILLNESS> ___ y/o with Stage IIIB serous ovarian cancer s/p optimal debulk surgery in ___, 2 rounds cycles of cis/taxol, with anastrazole in ___, bevacizumab in ___, weekly taxol, and most recently on Foslodex (please see ONC history below). Ms. ___ was recently discharged from the hospital on ___ for recurrent SBO. She was admitted under GYN-ONC surgery service and surgery was not indicated at that time. This is her ___ presentation for small bowel obstruction in the last 6 months. She also reports a 20 lb weight loss given decreased appetite. She says that over the weekend, she has been experiencing tightening in her epigastric area that is like a "contraction". This morning, she had a few episodes of emesis and she felt nauseated. She called her oncologists who recommended that she come in for an evaluation. She denies flatus, and her last BM was yesterday. Currently, she denies N/V but she does not have an appetite. She has no other complaints at this time. She was recently treated with amoxicillin for a sinusitis. She was started on omeprazole recently for her epigastric discomfort with improvement. She has no pelvic pain. No bloating. No vaginal/rectal bleeding. Normal urination, no dysuria, hematuria, or increased frequency. No chest pain or SOB. No bony pain. No headaches or neurologic changes. No skin or nail changes. ROS otherwise negative except for what is noted above. Oncology history: - Pt noted to have large pelvic mass at annual gyn exam. This finding was corroborated with pelvic US (17 cm mass in greatest dimension, encompassing both ovaries). CT torso also with bilateral adnexal involvmen and no evidence of disease outside of pelvis. Initial CA 125 on ___ was elevated at 72. - ___ optimal debulking surgery with grade 1 ovarian papillary serous carcinoma involving bilateral ovaries and fallopian tubes. Metastatic serous carcinoma was identified on the peritoneum, omentum, right paracolic gutter and appendix. - ___ C1D1 IV ___ - ___ BRCA neg - ___ IV/IP cis/taxol x 5 cycles - ___ - ___ OMED admit for Afib, febrile NTP - ___ rising CA 125, started anastrozole - ___ start weekly Taxol 60mg/m2 and Carboplatin auc 2 - ___ added neupogen 300mg x 3 days support to regimen - ___ completed 6 cycles weekly Taxol/Carboplatin. CT scan showed treatment response. - ___ start of treatment break - ___ restart weekly Taxol/Carboplatin- mild reaction- nasal congestion, palmar itching at end of Carboplatin infusion - ___ continue weekly Taxol 60mg/m2, added Bevacizumab 10mg/kg on D1 and D15 - ___ SBO- admitted to ___ - ___ CA125 down to 34 from 43; CT AP shows treatment response; CT chest with minimal bilateral pleural effusions may reflect pleural fluid, however small pleural tumor implants cannot be ruled out. - ___ resumed Taxol alone without ___ after their return from ___ - ___ SBO- admitted to ___ - ___ SBO- admitted to ___- Taxol held on ___ and ___ - ___ resume Taxol - ___ CT showed disease progression. Increased omental nodularity and increase in size of soft tissue peritoneal nodule adjacent to the sigmoid colon. - ___ Stop Taxol- start Faslodex - ___ Admitted to ___ for recurrent SBO - ___ Transferred to ___ - d/c ___ - ___ CT torso- stable disease, persistent low-grade partial SBO - Faslodex started on ___ and ___ <PAST MEDICAL HISTORY> PMH: - Paroxysmal atrial fibrillation x 2 episodes, most recently ___ - DJD L2/L3 - arthritis Oncology History: - ___: Noted to have a large pelvic mass on Gyn annual visit. An ultrasound on ___ revealed a 17 x 11 x 17 cm mass, which appeared to be composed of both ovaries. The right adnexal mass measured 12 x 9 x 10 cm and the left adnexal mass measured 8.9 x 7 cm. Minimal vascularity was identified within the mass and there was no evidence of free fluid or peritoneal carcinomatosis. Her CA-125 on ___ was 72. - ___: CT scan of the chest, abdomen and pelvis revealed findings strongly suspicious for malignant ovarian neoplasm with bilateral involvement. There was no evidence of extrapelvic disease. - ___: She underwent an exploratory laparoscopy, exploratory laparotomy, lysis of adhesions, and radical resection of abdominopelvic tumor, bilateral salpingo-oophorectomy, total abdominal hysterectomy, and infracolic omentectomy, resection of pelvic sidewall tumor, appendectomy, and cystoscopy. On completion of surgery she was completely staged and optimally cytoreduced. Final pathology showed grade 1 well differentiated ovarian papillary serous carcinoma on bilateral ovaries and fallopian tubes. Metastatic serous carcinoma was identified on the peritoneum, omentum, right paracolic gutter and appendix. Diagnosed with stage IIIB cytoreduced ovarian cancer. - ___ C1D1 IV ___ - ___: Negative BRCA1/BRCA2. - ___: 5 cycles of IP cisplatin/taxol - ___ - ___: Hospital admission for Afib, febrile neutropenia - ___ CT chest showed no evidence of intrathoracic metastatic disease. CT A/P showed enhancing 1.6 cm soft tissue nodule superior to the dome of the bladder. Enhancing right iliac lymph node measuring 7 mm and 6 mm perirectal lymph node. Minimal studding of the omentum without definitive soft tissue nodules. These findings raise the suspicion of recurrence. Soft tissue density along the lateral portions of the vaginal cuff may be related to postsurgical changes or recurrence of disease. Recommend pelvic MRI or PET for further evaluation. Unchanged appearance of left adrenal nodule and multiple liver hypodensities, consistent with cysts, as compared to prior study from ___. - ___: Started on Anastrazol due to CA-125 rise to 41 (steadily increased from nadir of 8.9 ___. - ___ start weekly Taxol 60mg/m2 and Carboplatin auc ___ added neupogen 300mg x 3 days support to regimen - ___ completed 6 cycles weekly Taxol/Carboplatin. CT scan showed treatment response. - ___ start of treatment break - ___ restart weekly Taxol/Carboplatin- mild reaction- nasal congestion, palmar itching at end of Carboplatin infusion - ___ continue weekly Taxol 60mg/m2, added Bevacizumab 10mg/kg on D1 and D15 - ___ CT Scan: No evidence of intrathoracic metastatic disease. Minimally increased right axillary lymph nodes. Interval decrease in size of multiple omental and pelvic implants and improvement in pelvic LAD suggests response to treatment. Stable, prominent, bilateral inguinal LNs. Soft tissue density along the right lateral portion. CA 125, ___ 29. - ___ SBO- admitted to ___ - ___ CA125 down to 34 from 43; CT AP shows treatment response; CT chest with minimal bilateral pleural effusions may reflect pleural fluid, however small pleural tumor implants cannot be ruled out. - ___ resumed Taxol alone - ___ SBO- admitted to ___ - ___ SBO- admitted to ___- Taxol held on ___ and ___ - ___ resume Taxol - ___ CT showed disease progression. Increased omental nodularity and increase in size of soft tissue peritoneal nodule adjacent to the sigmoid colon. - ___ Stop Taxol- start Faslodex <PAST MEDICAL HISTORY> recurrent stage IIIB ovarian cancer as above, anxiety. Denies history of asthma, diabetes, heart disease. Past Surgical History: right knee arthroscopy ___, hammertoe surgery at ___ ___ Ob/Gyn History: She is a G2P2. She reports SVDs in ___ and ___ without complications. She is post-menopausal, LMP in ___. Last Pap in ___, which was normal, and denies history of abnormal Pap smears. She does report a history of chlamydia, but otherwise has had no pelvic infections. Denies history of OCPs or HRT. <SOCIAL HISTORY> ___ <FAMILY HISTORY> She reports her mother had breast cancer at the age of ___ ___s a maternal great aunt. She had a grandmother w/ ovarian cancer. The patient reports that she is of ___ and ___ ancestry. <PHYSICAL EXAM> ADMISSION PHYSICAL EXAM <PERTINENT RESULTS> ADMISSION LABS ___ 09: 12AM NEUTS-59.9 ___ MONOS-9.6 EOS-1.2 BASOS-0.5 IM ___ AbsNeut-3.48 AbsLymp-1.66 AbsMono-0.56 AbsEos-0.07 AbsBaso-0.03 ___ 09: 12AM WBC-5.8 RBC-4.01 HGB-11.7 HCT-36.5 MCV-91 MCH-29.2 MCHC-32.1 RDW-14.4 RDWSD-48.2* ___ 09: 12AM CALCIUM-9.1 PHOSPHATE-3.9 MAGNESIUM-1.6 ___ 09: 12AM GLUCOSE-104* UREA N-9 CREAT-0.6 SODIUM-147* POTASSIUM-3.7 CHLORIDE-104 TOTAL CO2-25 ANION GAP-22* ___ 09: 24AM LACTATE-0.9 CTAP ___ Interval increase in dilatation of multiple loops of small bowel, currently measuring up to 6.3 cm, compared with 5.7 cm previously, with a relative caliber change in the low mid pelvis, with collapsed small bowel loop seen distally, some of which contain a small amount of fluid, consistent with worsening high-grade partial small bowel obstruction, likely due omental deposits or adhesions. Unchanged omental deposits and vaginal cuff soft tissue nodule. Unchanged left adrenal nodule, indeterminate in appearance on the current study. C. Diff pending <MEDICATIONS ON ADMISSION> - omeprazole 20mg QD - Zofran 8mg PRN - oxycodone 2.5mg q6hrs PRN pain (pt not taking) - colace <DISCHARGE MEDICATIONS> 1. Acetaminophen ___ mg PO Q6H: PRN Pain - Mild Reason for PRN duplicate override: Patient is NPO or unable to tolerate PO RX *acetaminophen 500 mg ___ tablet(s) by mouth every 6 hours Disp #*50 Tablet Refills: *1 2. Enoxaparin Sodium 40 mg SC Q24H Start: ___, First Dose: Next Routine Administration Time RX *enoxaparin 40 mg/0.4 mL 40 mg SC every 24 hours Disp #*28 Syringe Refills: *0 3. HYDROmorphone (Dilaudid) ___ mg PO Q4H: PRN Pain - Severe do not drive or drink alcohol while taking this medication RX *hydromorphone [Dilaudid] 2 mg ___ tablet(s) by mouth every 4 hours Disp #*30 Tablet Refills: *0 4. Ibuprofen 600 mg PO Q6H: PRN Pain - Moderate take with food. RX *ibuprofen 600 mg 1 tablet(s) by mouth every 6 hours Disp #*50 Tablet Refills: *1 5. LORazepam 0.25 mg PO QHS: PRN insomnia 6. Docusate Sodium 100 mg PO DAILY RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice daily Disp #*60 Capsule Refills: *1 7. Omeprazole 20 mg PO DAILY <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> ovarian cancer partial small bowel obstruction <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Dear Ms. ___, You were admitted to the GYN oncology service with abdominal pain, nausea, and vomiting for management of a partial small bowel obstruction in the setting of your ovarian cancer. You underwent surgery to relieve this partial obstruction. You were admitted to the ICU after your surgery because of low blood pressures, and then were transferred to the gynecologic oncology service once your blood pressures were stable. You have recovered well after your operation, and the team feels that you are safe to be discharged home. Please follow these instructions: Abdominal instructions: * Take your medications as prescribed. We recommend you take non-narcotics (i.e. Tylenol, ibuprofen) regularly for the first few days post-operatively, and use the narcotic as needed. As you start to feel better and need less medication, you should decrease/stop the narcotic first. * Do not drive while taking narcotics. * Do not combine narcotic and sedative medications or alcohol. * Do not take more than 4000mg acetaminophen (tylenol) in 24 hrs. * No strenuous activity until your post-op appointment. * Nothing in the vagina (no tampons, no douching, no sex) for 12 weeks. * No heavy lifting of objects >10 lbs for 6 weeks. * You may eat a regular diet. * It is safe to walk up stairs. * 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. * You should remove your port site dressings ___ days after your surgery, if they have not already been removed in the hospital. Leave your steri-strips on. If they are still on after ___ days from surgery, you may remove them. * If you have staples, they will be removed at your follow-up visit. . To reach medical records to get the records from this hospitalization sent to your doctor at home, call ___. . Call your doctor at ___ for: * fever > 100.4 * severe abdominal pain * difficulty urinating * vaginal bleeding requiring >1 pad/hr * abnormal vaginal discharge * redness or drainage from incision * nausea/vomiting where you are unable to keep down fluids/food or your medication * chest pain or difficulty breathing * onset of any concerning symptoms
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Ms. ___ is a ___ female with a history of recurrent stage IIIB ovarian cancer originally diagnosed in ___ and reccurrence in ___ s/p ex-lap TAH-BSO debulk in ___, recently transitioned to Faslodex on ___, who presents with her ___ episode of partial SBO in 6 months. In the emergency department, she was overall well-appearing with normal stable vital signs. She was made NPO and started on maintenance IV fluids. CT abdomen and pelvis (___) was notable for "interval increase in dilatation of multiple loops of small bowel, currently measuring up to 6.3 cm, compared with 5.7 cm previously, with a relative caliber change in the low mid pelvis, with collapsed small bowel loop seen distally, some of which contain a small amount of fluid, consistent with worsening high-grade partial small bowel obstruction, likely due omental deposits or adhesions. Unchanged omental deposits and vaginal cuff soft tissue nodule. Unchanged left adrenal nodule, indeterminate in appearance on the current study." . Patient developed further nausea/vomiting on hospital day 2, so a nasogastric tube was placed. She received IV reglan and IV Ativan for nausea. Patient was counseled on the risks/benefits of an OR procedure, and she made the decision for surgical intervention after discussion with GYN oncology, colorectal surgery, and medical oncology. She was evaluated by nutrition prior to surgery, who recommended placement of a PICC line for total parenteral nutrition. PICC line was placed ___. Patient underwent exploratory laparotomy, lysis of adhesions, small bowel resection and anastomosis, bladder oversew, and cystoscopy on ___. Her post-operative course is detailed as follows. Immediately postoperatively, she was admitted to the ICU given persistent post operative hypotension requiring pressors. = = = = = = = = = ================================================================ ICU course: Her pain was controlled with an epidural. She received 24 hours of flagyl post operatively. Her electrolytes were monitored twice daily and repleted as needed. Her NGT was kept in place, and she was kept NPO. She was started on TPN on ___. She also had a left lower quadrant drain in place that remained on transfer to floor. Her foley catheter was kept in place until ___ for bladder oversew. She developed a fever on ___. Urine and blood cultures, as well as chest XR, were negative. Given that there was a small enterotomy intra-operatively, with spillage, cipro/flagyl was started on ___. Her epidural was capped on ___ given concern it was contributing to her hypotension and then pulled the next day. She was transitioned to dilaudid PCA and toradol. She was slowly weaned off pressors, and she defervesced on antibiotics. Her need for pressors was felt to be secondary to epidural, fluid shifts and intravascular depletion. Her NGT was clamped on ___, and d/c'd on ___. She had a bowel movement on ___ and ___. She received 1 unit of pRBCs for anemia on ___. She was stable off of pressors for >24 hrs by the afternoon of ___ so she was transferred to the GYN service and out of the FICU. = = = = = = = = = = = = = = = = = ================================================================ On the GYN floor, her antibiotics were discontinued on ___, given no further concerns for peritonitis with stable vital signs and exam. Her left lower quadrant drain was d/c'd on ___ as it had minimal serous drainage. Her diet was gradually advanced to a regular diet, though she was supported with TPN until ___. She was transitioned to PO pain medications as well, and had minimal pain at the time of discharge. On POD#9, the patient did report frequent bowel movements. It is unclear whether it is a result of her extensive small bowel resection versus a C. Diff infection. A C. Diff stool culture was obtained, though the patient elected to wait for the results at home, and to be treated as an outpatient if needed. The patient demonstrated that she did not have any evidence of hypovolemia from her frequent bowel movements, with stable vital signs and ability to po rehydrate as needed. She was continued on her home Ativan for anxiety, as needed, and received Lovenox for VTE prophylaxis while in house. ON ___, POD#9, she was tolerating a regular diet and ambulating independently. Her PICC line was removed. She was then discharged home in stable condition with outpatient follow-up scheduled. She will be continued on an extended course of VTE anticoagulation with lovenox daily.
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11138201-DS-20
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> thickened endometrium <MAJOR SURGICAL OR INVASIVE PROCEDURE> attempted hysteroscopy endometrial biopsy under ultrasound guidance <HISTORY OF PRESENT ILLNESS> The patient is a ___ postmenopausal female, who was evaluated in an outside hospital emergency room for history of epigastric abdominal pain. Abdominal pelvic CT at that time demonstrated a markedly thickened endometrial cavity. The patient was then seen in the office, and recommendation was made for endometrial biopsy; however the patient declined at that time. Pelvic ultrasound was then performed which showed a 17-mm endometrial stripe with vascular flow. Given these findings, the patient was counseled for biopsy; however given the patient's intolerance to exam, decision was made to proceed with hysteroscopy, D and C in the OR. <PAST MEDICAL HISTORY> SMA stenosis, hypercholesterolemia, HTN, DM, alzheimer-type dementia <SOCIAL HISTORY> ___ <FAMILY HISTORY> Noncontributory <PHYSICAL EXAM> AF VSS NAD CTAB RRR Abd soft, nontender, nondistended, no r/g. Gyn minimal vaginal bleeding Ext no edema <PERTINENT RESULTS> ___ 07: 52PM GLUCOSE-133* UREA N-14 CREAT-0.8 SODIUM-140 POTASSIUM-4.2 CHLORIDE-104 TOTAL CO2-27 ANION GAP-13 ___ 07: 52PM CALCIUM-9.4 PHOSPHATE-3.4 MAGNESIUM-1.8 ___ 07: 52PM WBC-9.7 RBC-3.71* HGB-8.0* HCT-25.6* MCV-69* MCH-21.4* MCHC-31.1 RDW-15.6* ___ 07: 52PM PLT COUNT-318 <MEDICATIONS ON ADMISSION> Preadmission medications listed are correct and complete. Information was obtained from ___ record. 1. Amlodipine 2.5 mg PO HS 2. GlyBURIDE 5 mg PO BID 3. Omeprazole 20 mg PO DAILY 4. MetFORMIN (Glucophage) 1000 mg PO BID 5. Mirtazapine 7.5 mg PO HS 6. Pravastatin 40 mg PO HS 7. Lisinopril 20 mg PO DAILY 8. Hydrochlorothiazide 25 mg PO DAILY <DISCHARGE MEDICATIONS> 1. OxycoDONE (Immediate Release) 5 mg PO Q4H: PRN pain RX *oxycodone 5 mg 1 tablet(s) by mouth every four (4) hours Disp #*20 Tablet Refills: *0 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. Acetaminophen 325-650 mg PO Q6H: PRN pain when tolerating po RX *acetaminophen 500 mg ___ tablet(s) by mouth every six (6) hours Disp #*40 Tablet Refills: *0 4. Amlodipine 2.5 mg PO HS 5. GlyBURIDE 5 mg PO BID 6. Hydrochlorothiazide 25 mg PO DAILY 7. Lisinopril 20 mg PO DAILY 8. MetFORMIN (Glucophage) 1000 mg PO BID 9. Mirtazapine 7.5 mg PO HS 10. Omeprazole 20 mg PO DAILY 11. Pravastatin 40 mg PO HS <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> thickened endometrium, uterine perforation <DISCHARGE CONDITION> Mental Status: Clear and coherent. Activity Status: Ambulatory - Independent. Level of Consciousness: Alert and interactive. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Dear Ms. ___, You are being discharged home after having an endometrial biopsy and attempted hysteroscopy complicated by uterine perforation. General instructions: * Take your medications as prescribed. * Do not drive while taking narcotics. * Take a stool softener such as colace while taking narcotics to prevent constipation * Do not combine narcotic and sedative medications or alcohol * Do not take more than 4000mg acetaminophen (APAP) in 24 hrs * No strenuous activity until your post-op appointment * Nothing in the vagina (no tampons, no douching, no sex), no heavy lifting of objects >10lbs for 6 weeks. * You may eat a regular diet 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 * nausea/vomiting where you are unable to keep down fluids/food or your medication
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On ___, Ms. ___ was admitted to the gynecology service after undergoing an attempted hysteroscopy complicated by perforation of the posterior fornix followed by endometrial biopsy under ultrsound guidance. She was admitted for observation of her perforation. 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 tylenol. Her diet was advanced without difficulty and she was transitioned to oxycodone and tylenol. She remained hemodynamically stable. 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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11138414-DS-11
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Penicillins <ATTENDING> ___ <CHIEF COMPLAINT> vaginal bleeding <MAJOR SURGICAL OR INVASIVE PROCEDURE> none <HISTORY OF PRESENT ILLNESS> ___ yo G2P1 at 29 ___ ___ age presents with vaginal bleeding since ___. Describes as dark blood, amount c/w period, soaked through underwear but not pants. + ctx q ___ min, started 1800, describes as crampy. + FM. No LOF. No abd pain besides cramping. No abd trauma. No recent intercourse. PNC: ___ ___ by LMP c/w ___ tri ultrasound A+/Ab-/RPRNR/RI/HBsAg-/GBS unk/VI/Hgb nl/GLT 118/HIV-/CF- ___ FFS S=D, no anomalies, placenta ant with no previa <PAST MEDICAL HISTORY> POB: ___ SVD 8#8 at 41 ___ age c/b GDMA1 PGYN: HSVII, + abnl PAP with bx showing HPV changes. + hx CT. ___ GC-/CT-, ___ BV neg, yeast neg PMH: benign PSH: wisdom teeth <SOCIAL HISTORY> no t,e,d. married, presents with husband. <PHYSICAL EXAM> 97.6 70 18 110/61 NAD CTAB RRR abd gravid, soft, mild suprapub tend, no rebound/guarding SSE approx 3 cc dark blood and old appearing clot in vault. cx appears long and sl open SVE long, ext os 2, int os 1, high FHT 130, mod var, AGA, no decels toco q 2 min <PERTINENT RESULTS> TAUS frank breech, BPP ___, AFI 18, EFW 1360 gm (~50%), placenta ant, no previa ___ WBC-12.4 RBC-3.78* HGB-12.7 HCT-35.0PLT COUNT-223 ___ PTT-25.4 ___ FIBRINOGEN-460 URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG cocaine-NEG amphetmn-NEG mthdone-NEG URINE COLOR-Straw APPEAR-Clear SP ___ URINE BLOOD-SM NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-5.5 LEUK-NEG <MEDICATIONS ON ADMISSION> PNV, acyclovir <DISCHARGE MEDICATIONS> PNV, acyclovir <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> SIUP @ 29 ___. Probable small placenta abruptio. Pre-term contractions. <DISCHARGE CONDITION> stable <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Modified bedrest. Restrictions were discussed with patient.
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Ms ___ was admitted to the antepartum service after a vaginal bleed. She is Rh+. The abruption labs were normal. She initially was contracting. Her cervical exam remained 1/long/high. She awas initially give Nifedipine but this was discontinued due to hypotension. She then was placed on Magnesium. She was given steroids for fetal lung maturity.NICU was consulted and counseled the patient. The Magneisum was discontinued after she was Betamethasone complete. She did not contract after the magnesium was discontinued. Fetal testing was reassuring with EFW 1360 grams (50%), ___ placenta with out evidence of placenta previa. On day of admission ___ she also has BPP ___, AFI 18 breech. She had no bleeding for 4 days and was discharged home.
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11139232-DS-11
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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> none <HISTORY OF PRESENT ILLNESS> ___ yo G10 ___ at 20w6d with 'a few weeks' of cough and SOB. SOB acutely worsened today with wheezing. No fevers, chills, rigors, nausea, vomiting, diarrhea. No malaise, aches, myalgias. No ctx, VB, LOF. +FM. PNC: - ___ ___ by first trimester US B NEG/ ABS RH IG/ RI/ RPR NR/ HBsAg - / HIV -/ GC CT - - FFS - normal - Issues: obesity <PAST MEDICAL HISTORY> OBHx: - SVD x 7 - sab x 2 D&C GynHx: denies STI PMH: asthma - no meds, no hospitlaizations or intubations PSH: tonsils, D&C Meds: PNV All: NKDA SHx: ___ <FAMILY HISTORY> non-contributory <PHYSICAL EXAM> CONSTITUTIONAL: normal HEENT: normal, MMM NEURO: alert, appropriate, oriented x 4 RESP: no increased WOB HEART: extremities warm and well perfused ABDOMEN: gravid, non-tender EXTREMITIES: non-tender, no edema FHR: present at a normal rate <PERTINENT RESULTS> ___ 07: 30AM BLOOD WBC-14.5* RBC-3.22* Hgb-10.3* Hct-31.3* MCV-97 MCH-32.0 MCHC-32.9 RDW-12.5 RDWSD-44.1 Plt ___ ___ 05: 45PM BLOOD WBC-17.4* RBC-3.47* Hgb-11.4 Hct-33.4* MCV-96 MCH-32.9* MCHC-34.1 RDW-12.6 RDWSD-44.3 Plt ___ ___ 07: 30AM BLOOD Neuts-67.9 Lymphs-18.7* Monos-7.2 Eos-5.4 Baso-0.3 Im ___ AbsNeut-9.84* AbsLymp-2.71 AbsMono-1.05* AbsEos-0.79* AbsBaso-0.05 ___ 05: 45PM BLOOD Neuts-77.3* Lymphs-12.5* Monos-6.0 Eos-3.4 Baso-0.2 Im ___ AbsNeut-13.47*# AbsLymp-2.18 AbsMono-1.05* AbsEos-0.60* AbsBaso-0.04 ___ 07: 30AM BLOOD Plt ___ ___ 05: 45PM BLOOD Plt ___ ___ 05: 45PM BLOOD Glucose-97 UreaN-4* Creat-0.5 Na-136 K-4.2 Cl-100 HCO3-24 AnGap-16 ___ 05: 45PM BLOOD cTropnT-<0.01 ___ 05: 45PM BLOOD D-Dimer-893* Sputum Culture x 2 contaminated <DISCHARGE INSTRUCTIONS> You were admitted to the antepartum service for treatment of an asthma exacerbation in the setting of pneumonia. You were started on antibiotic treatment and given inhalers for your asthma. You should continue taking the azithromycin for 5 days.
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On ___, Ms. ___ was admitted to the antepartum service at 20w6d for asthma exacerbation in the setting of community acquire pneumonia. CXR performed in the ED showed patchy right upper lobe opacity concerning for pneumonia with streaky bibasilar atelectasis. Her WBC count was noted to be elevated at 17.4 without any bandemia, which trended down to 14.5 on HD#2. She was given a nebulizer treatment and IV hydration. She was given a dose of IM Ceftriaxone 1g and was continued on PO azithromycin for a ___y ___, she was afebrile with stable vital signs, saturating 95-96% on RA without any evidence of respiratory distress. She was discharged home with outpatient follow up scheduled. Discharge Medications: 1. Albuterol Inhaler ___ PUFF IH Q4H:PRN wheezing RX *albuterol sulfate [ProAir HFA] 90 mcg ___ puff INH every four (4) hours Disp #*1 Inhaler Refills:*3 2. Azithromycin 250 mg PO Q24H RX *azithromycin 250 mg 1 tablet(s) by mouth once a day Disp #*2 Tablet Refills:*0 Discharge Disposition: Home Discharge Diagnosis: asthma exacerbation community acquired pneumonia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___
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11140251-DS-18
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> transaminitis, concern for pre-eclampsia <MAJOR SURGICAL OR INVASIVE PROCEDURE> none <HISTORY OF PRESENT ILLNESS> ___ yo G4P1021 at 32w3d ___ ___ presents for antepartum admission to r/o superimposed preeclampsia. Has ICP, T1DM and HTN; seen 2x/week for fetal testing and prenatal visits. Yesterday she c/o worsening itching despite ursodiol 600 mg BID. She was normotensive with no protein on urine dip, but had elevated LFTs on lab draw. LFTs were normal 2 weeks prior. F/u bile acids were drawn and are pending. On questioning she notes increasing nausea since the weekend and also chills. Continues to have persistent itching during the day. Not taking hydroxyzine at night because itching improves at night. Notes dark urine. UA dipstick negative. Urine cx collected in clinic yesterday and ending. Tbili yesterday normal at 0.4. Went to ___ last week for ___ opinion, reports there that bile acids were 33 and LFTs were in ___. Is very concerned that she should be delivered prior to 36 weeks. <PAST MEDICAL HISTORY> Issues: - ICP (dx on ___, total serum bile acids 17.4) - T1DM on insulin pump with CGM. Followed by Dr. ___. Has proliferative retinopathy. - CHTN on labetalol 100 mg po bid. Normotensive - Hypothyroidism, on levothyroxine, followed by ___ - IVF pregnancy with vanishing twin (di/di); spontaneous reduction to ___ in early first trimester - AMA - s/p genetics consult, normal NT, declined cfDNA testing - Prior CS for retinopathy. R C/S scheduled for ___ at 36w2d Labs: -B+/neg -Rub ___ NR/HbsAg neg/HIV neg/GCCT neg/ucx neg -Baseline PIH labs: 24h urine 84mg, Cr 0.8, ALT 19, AST 34 -Baseline DM eval: EKG NSR. S/p cardiology consult on ___. No maternal echo seen in OMR and not in cardiology recommendations. -Normal fetal echo. A1C 4.9 on ___ -Proliferative retinopathy, last ophtho exam ___ OBHx: - ___ FT Csection for retinopathy, 3000g. Reports postpartum pre-e but not seen in medical record - SAB x 2 GynHx: No abnl paps, no STD. Last pap ___, nl. PMH: Hypothyroidism, CHTN, DM PSH: c-section <SOCIAL HISTORY> ___ <FAMILY HISTORY> non-contributory <PHYSICAL EXAM> (on admission) Gen: anxious appearing, no acute distress Vital signs: BP 120/56 BPP ___ on ___. Cephalic. Last US for growth on ___: EFW 1623g (46%ile) <PERTINENT RESULTS> ___ WBC-11.0 RBC-3.58 Hgb-10.5 Hct-31.8 MCV-89 Plt-147 ___ Creat-0.6 UricAcd-3.7 Hapto-22 ___ BLOOD ALT-171 AST-150 AlkPhos-190 TotBili-0.4 ___ BLOOD ALT-190 AST-161 LD(LDH)-206 TotBili-0.5 BILE ACIDS Results Pending ___ URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-2 pH-7.0 Leuks-LG ___ URINE RBC-1 WBC-2 Bacteri-FEW Yeast-NONE Epi-9 ___ URINE pH-7 Hours-24 Volume-3525 Creat-36 TotProt-8 Prot/Cr-0.2 ___ URINE 24Creat-1269 24Prot-282 URINE CULTURE (Final ___: MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION <MEDICATIONS ON ADMISSION> insulin PNV labetalol 100 mg po bid levothyroxine 137mcg 9 pills/week baby ASA <DISCHARGE MEDICATIONS> 1. s-adenosylmethionine 400 mg oral BID RX *s-adenosylmethionine [___] 400 mg 1 tablet(s) by mouth twice a day Disp #*30 Tablet Refills: *1 2. Aspirin 81 mg PO DAILY 3. Insulin Pump SC (Self Administering Medication)Insulin Aspart (Novolog) (non-formulary) Basal Rates: Midnight - 0100: .55 Units/Hr 100 - 200: .65 Units/Hr 200 - 700: .98 Units/Hr 700 - 1100: 2.6 Units/Hr 11 - 1530: 1.65 Units/Hr 1530 - 1800: .45 Units/Hr 1800 - 21: 30: 2.2 Units/Hr 21: 30 - 0000: 1.05 Units/Hr Meal Bolus Rates: Breakfast = 1: 6.5 Lunch = 1: 7.5 Dinner = 1: 10 High Bolus: Correction Factor = 1: 40 Correct To ___ mg/dL 4. Labetalol 100 mg PO BID 5. Levothyroxine Sodium 137 mcg PO DAILY 6. Omeprazole 20 mg PO DAILY 7. Prenatal Vitamins 1 TAB PO DAILY 8. Ursodiol 600 mg PO BID <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> chronic HTN, cholestasis of pregnancy, T1DM <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Ms. ___, You were admitted to the Antepartum service in the setting of an evaluation for pre-eclampsia. The lab work and testing obtained during your admission was reassuring and you do not have a diagnosis of pre-eclampsia at this time. The team feels that you are safe for discharge home with appropriate outpatient follow up. You were started on a new medication called s-adenosyl methionine, please take as prescribed. Please call the office with any questions or concerns.
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___ y/o G4P1021 with ICP, TIDM admitted at 32w3d with new tranaminitis. She was admitted for blood pressure monitoring and a 24 hour urine collection. Repeat LFTs were stable. Her 24 hour urine was negative (282mg) and she remained normotensive for the duration of the admission. She was continued on her home dose of Labetolol (100mg bid) and Urosodiol (600mg bid). Given her persistent pruritis and new transaminitis, she was started on ___ prior to discharge. Repeat bile acids were pending at the time of discharge. . In regards to her T1DM, ___ was consulted and no changes were made insulin regimen. Her fingersticks were in good range. She did not receive betamethasone. . Ms ___ had reactive NSTs while she was here. She was discharged home in stable condition on ___ and will continue to have close outpatient follow up with twice weekly testing.
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11140251-DS-21
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> cholestasis, TIDM in pregnancy with poor control <MAJOR SURGICAL OR INVASIVE PROCEDURE> Repeat low transverse cesarean delivery Postpartum salpingectomy <HISTORY OF PRESENT ILLNESS> ___ G4___ with T1DM, hypothyroidism, ICP, cHTN, and anxiety/OCD presents for direct admission for glycemic management and fetal surveillance. Pt has been followed by Dr ___ at ___ and ___ had erratic ___ during this pregnancy, with multiple presentations to the ED with severe hypoglycemia. There is concern pt is overtreating her ___. In regards to her ICP, pt has been taking Ursodiol since the start of pregnancy given hx of likely autoimmune hepatitis and PBC. Pt followed by hepatology (Dr ___ and has had bile acids checked weekly. They had been in the normal range for many weeks but most recently on ___ had become elevated (21.2). Her LFTs were normal on ___. Pt continues to have itching and feels that her level of itching correlates with her bile acid levels. Pt anxious about risk of fetal demise in setting of ICP and feels more comfortable with increased fetal monitoring. She denies any recent headaches or visual changes. She denies any vaginal bleeding, lof, or painful contractions. Reports active fetal movement. <PAST MEDICAL HISTORY> PNC: - ___ ___ by LMP c/w first trimester ultrasound - Labs: B+/Ab-,RPRnr,RI,HbsAg-,HIV,GBSunk - LR NIPT, nl FFS ISSUES: *) T1DM - ASA 81mg - followed by Dr ___ at ___, on Novolog pump - hx proliferative diabetic retinopathy - ___ 4.5% *) cHTN: takes Labetalol 100mg BID - baseline 24hr urine 194mg (___) - hx preterm preeclampsia in prior pregnancy - most recent EFW (___) *) Tib/fib bracture in early pregnancy: f/b ortho *) AMA *) ? Zika exposure: in ___ in first trimester, testing deferred; [ ] serial u/s *) hypothyroidism: takes Levothyroxine, managed by ___ - ___ 1.12, fT4 1.09 *) cholestasis: f/b BI Hepatology; bile acids/LFTs normalized, on ursodiol 1500mg daily + cholestyramine 4g/day - nl LFTs ___ [ ] weekly bile acids *) hx severe anxiety/OCD: has declined social services/psych in the past *) FHx of breast cancer: f/b Dr. ___ mammogram, MRI surveillance; breast u/s ___ BIRADS 1; [ ] mammogram and clinical follow up three months post-partum OBHx: - G1: ___ 38w4d 6lbs7oz M Spin primary c/s, IVF pregnancy - G2: ___ 10w6d SAB s/p D&C - G3: ___ 33w5d 2145g F R C/S, IVF pregnancy - G4: current GynHx: - Hx of anovulation d/t hypothalamic amenorrhea OCPs since her ___ was on OCPs in ___ with withdrawal bleeding Last pap: ___ NIL, HPV neg Last mammogram: ___, breast biopsy ___ benign c/b hematoma PMH: Type 1 diabetes, cHTN, cholestasis, GERD, anxiety/OCD, hypothyroidism PSH: c section x2, D&C <SOCIAL HISTORY> ___ <FAMILY HISTORY> non-contributory <PHYSICAL EXAM> On admission: Gen: A&O, comfortable VS: 97.8, 125/80, 74, 18 ___ 61 -> 80s Abd: soft, gravid, nontender Ext: 1+ pedal edema bilat. no calf tenderness US (___): vtx, BPP ___, AFI 16.4 Date: ___ Time: ___ FHT: 120s, mod var, +accels, ? quick var to 100 x 15 sec assoc with loss of pickup; otherwise reactive Toco no ctxs On discharge: Vitals: 24 HR Data (last updated ___ @ 2337) Temp: 98.3 (Tm 98.3), BP: 148/81 (131-179/75-98), HR: 64 (62-73), RR: 18, O2 sat: 98% (97-99), O2 delivery: room air Gen: NAD, A&Ox3 Declined exam <PERTINENT RESULTS> ___ WBC-8.7 RBC-3.56 Hgb-10.9 Hct-33.5 MCV-94 Plt-135 ___ WBC-8.5 RBC-3.43 Hgb-10.6 Hct-31.7 MCV-92 Plt-119 ___ WBC-8.0 RBC-3.88 Hgb-11.8 Hct-35.9 MCV-93 Plt-129 ___ 07: 00PM BLOOD WBC-6.6 RBC-2.88* Hgb-8.9* Hct-27.1* MCV-94 MCH-30.9 MCHC-32.8 RDW-15.0 RDWSD-51.1* Plt ___ ___ ___ PTT-25.6 ___ ___ ___ PTT-25.2 ___ ___ ___ PTT-25.6 ___ ___ BLOOD Glucose-209* ___ BLOOD Creat-0.7 ___ BLOOD Creat-0.7 ___ 07: 00PM BLOOD Creat-0.7 ___ BLOOD ALT-12 AST-19 AlkPhos-183* TotBili-0.3 ___ BLOOD ALT-10 AST-18 ___ BLOOD ALT-12 AST-19 ___ BLOOD ALT-12 AST-19 ___ BLOOD ALT-14 AST-24 ___ 07: 00PM BLOOD ALT-15 AST-28 ___ BLOOD UricAcd-4.2 ___ BLOOD %HbA1c-4.5 eAG-82 ___ BLOOD TSH-2.6 ___ BLOOD Free T4-1.1 ___ 10: 55 BILE ACIDS Test Result Reference Range/Units CHOLIC ACID <0.5 < OR = 1.8 umol/L DEOXYCHOLIC ACID <0.5 < OR = 2.4 umol/L CHENODEOXYCHOLIC ACID <0.5 < OR = 3.1 umol/L TOTAL BILE ACIDS <1.5 < OR = 6.8 umol/L ___ 06: 28 BILE ACIDS Test Result Reference Range/Units CHOLIC ACID 1.1 < OR = 1.8 umol/L DEOXYCHOLIC ACID 0.6 < OR = 2.4 umol/L CHENODEOXYCHOLIC ACID <0.5 < OR = 3.1 umol/L TOTAL BILE ACIDS 1.7 < OR = 6.8 umol/L ___ 06: 54 BILE ACIDS Test Result Reference Range/Units CHOLIC ACID <0.5 < OR = 1.8 umol/L DEOXYCHOLIC ACID <0.5 < OR = 2.4 umol/L CHENODEOXYCHOLIC ACID <0.5 < OR = 3.1 umol/L TOTAL BILE ACIDS <1.5 < OR = 6.8 umol/L <MEDICATIONS ON ADMISSION> - Novolog pump - Ursodiol 900 qAM, 600 qPM - cholestyramine - Labetalol 100mg bid - Levothyroxine 137mg tabs ___ 1.5 tabs, ___ 1 tab, ___ 2 tabs) - PNV - Colace - Fe - baby ASA <DISCHARGE MEDICATIONS> 1. Bisacodyl ___AILY: PRN Constipation RX *bisacodyl 10 mg 1 suppository(s) rectally DAILY Disp #*10 Suppository Refills: *0 2. Docusate Sodium 100 mg PO TID RX *docusate sodium 100 mg 1 capsule(s) by mouth twice daily Disp #*40 Capsule Refills: *2 3. Ibuprofen 600 mg PO Q6H: PRN Pain RX *ibuprofen 600 mg 1 tablet(s) by mouth every 6 hours Disp #*40 Tablet Refills: *2 4. NIFEdipine (Extended Release) 30 mg PO BID RX *nifedipine 30 mg 1 tablet(s) by mouth twice per day Disp #*60 Tablet Refills: *3 RX *nifedipine 30 mg 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills: *0 5. OxyCODONE (Immediate Release) ___ mg PO Q4H: PRN pain RX *oxycodone 5 mg 1 tablet(s) by mouth q5 hours Disp #*8 Tablet Refills: *0 6. Polyethylene Glycol 17 g PO DAILY: PRN Constipation - First Line RX *polyethylene glycol 3350 [Miralax] 17 gram/dose 17 g powder(s) by mouth daily Refills: *2 7. Senna 8.6 mg PO BID: PRN Constipation - First Line Reason for PRN duplicate override: Alternating agents for similar severity RX *sennosides [senna] 8.6 mg 1 tablet by mouth twice daily Disp #*30 Tablet Refills: *2 8. Insulin Pump SC (Self Administering Medication)Insulin Aspart (Novolog) (non-formulary) Basal Rates: Midnight - 0400: .4 Units/Hr 0400 - 0700: .7 Units/Hr 0700 - 1000: 1 Units/Hr 1000 - 1400: .6 Units/Hr 1400 - 1800: .3 Units/Hr 1800 - Midnight: .4 Units/Hr Meal Bolus Rates: Breakfast = 1: 10 Lunch = 1: 10 Dinner = 1: 10 Snacks = 1: 10 High Bolus: Correction Factor = 1: 35 Correct To ___ mg/dL Use of ___ medical equipment: Insulin pump Reason for use: medically necessary and justified as ___ cannot provide this type of equipment or suitable alternative not appropriate. Provider acknowledges patient competent 9. Labetalol 200 mg PO Q8H RX *labetalol 200 mg 1 tablet(s) by mouth every 8 hours Disp #*40 Tablet Refills: *2 10. Levothyroxine Sodium 137 mcg PO DAILY 11. Ursodiol 500 mg PO BID <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> Type I Diabetes Mellitus Chronic hypertension Superimposed preeclampsia Intrahepatic cholestasis Postpartum <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> ___, Congratulations on the birth of your baby! You have recovered well and are ready to go home. Please follow these instructions: High blood pressure: You should continue to monitor your blood pressure at home and take medications as prescribed. If the systolic blood pressure (top number) is more than 159 or the diastolic blood pressure (bottom number) is more than 104, please call your doctor. If the systolic blood pressure is less than 110 or the diastolic blood pressure is less than 60, please don't take the medications and call your doctor. Type 1 Diabetes Continue to take insulin by pump and manage as you normally do. Please follow-up with your ___ providers. You should avoid tylenol use if relying on CGM. Constipation Your constipation should improve as you move around more postpartum and given no longer pregnant. You should continue to take the colace three times daily, although you can decrease this if you start to have loose stools If constipated: Step 1: Add senna Step 2: Add miralax once per day (dissolve powder in ___ oz of liquid) Step 3: Rectal suppository (bisacodyl) If none of these things work, you can call the doctor for further advice. If they do work, then continue to use them, but try to gradually peel off the medications one step at a time. General instructions: Nothing in the vagina for 6 weeks (No sex, douching, tampons) No heavy lifting for 6 weeks Do not drive while taking narcotics (i.e. Dilaudid, Percocet) Do not take more than 4000mg acetaminophen (tylenol) in 24 hrs Do not take more than 2400mg ibuprofen in 24 hrs Please call the on-call doctor at ___ if you develop shortness of breath, dizziness, palpitations, fever of 100.4 or above, abdominal pain, increased redness or drainage from your incision, nausea/vomiting, heavy vaginal bleeding, or any other concerns.
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___ yo G4P2012 with T1DM, hypothyroidism, intrahepatic cholestasis of pregnancy, cHTN, and anxiety/OCD admitted at 33w0d for glycemic management and fetal surveillance. . *) T1DM: ___ was consulted and followed her closely throughout her admission. Although she was maintained on her insulin pump and her settings were frequently adjusted, she continued to have labile fingersticks with episodes of hypo and hyperglycemia. She was on an insulin drip intrapartum, and transitioned to her pump postpartum. *) ICP: Cholestasis had previously been diagnosed by generalized pruritis and intermittently elevated bile acids. She was continued on Ursodiol and cholestyramine per her outpatient hepatologist. In addition, weekly bile acids continued to be followed, although they remained in normal range while she was here. Postpartum, she was reduced to her pre-pregnancy doses of ursodiol. *) cHTN with superimposed preeclampsia: Ms ___ was continued on her home dose of Labetalol (100mg BID) and baby aspirin. Her blood pressures remained mostly in normal range with occasional mild range BPs antepartum. Intrapartum, she ruled in for preeclampsia with an elevated urinary protein to creatinine ratio. After delivery, her blood pressures became elevated and her medications were increased to labetalol 200 mg q8h and nifedipine CR 30 mg BID. She did not have severe features and did not receive magnesium. *) hypothyroidism: continue Levothyroxine 137 mcg 10 times/week antepartum and then resumed 137 mcg daily dosing postpartum. *) Anxiety: not on medications. Euthymic throughout admission. She was seen by Social Work. *) Fetal status prior to delivery was reassuring with daily NSTs and twice weekly BPPs. Betamethasone was deferred given her known diabetes. *) Delivery: She underwent a scheduled repeat low transverse cesarean delivery and bilateral salpingectomy on ___ at 36 weeks 0 days. The infant had APGARS 8 and 9 and weighed 2695 grams. The procedure was uncomplicated. *) Post-op: Her postpartum course was uncomplicated. Her pain was treated with oral pain medications. She ambulated and her foley was discontinued and she voided spontaneously. Her diet was advanced without incident. By postpartum day 4, she was tolerating a regular diet, ambulating independently, and pain was controlled with oral medications. She was then discharged home in stable condition with postpartum outpatient follow-up scheduled.
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11142150-DS-15
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> labial abscesses <MAJOR SURGICAL OR INVASIVE PROCEDURE> incision and drainage <HISTORY OF PRESENT ILLNESS> The patient is a ___ G6, P4, who initially presented to the primary care office with a labial lesion on ___. She had an incision and drainage in the office with a culture showing methicillin-sensitive Staph aureus. She was placed on antibiotics but this failed to diminish her symptoms and she presented to the emergency room on the evening of ___ with complaint of continued abscess. At this point it was felt that her labia would benefit from incision and drainage in the operating room, and she was added onto the schedule for ___. She was kept n.p.o. the evening prior to the procedure and all consents were signed and placed in the chart. <PAST MEDICAL HISTORY> OB: - G6P4 - SVD x 2 - LTCS x 2 - SAB, TAB GYN: - Pap smear after delivery 10 months ago. PMH: - HCV - No history of diabetes, chronic steroid use, immunodificiency PSH: - LTCS x2, PPTL <SOCIAL HISTORY> ___ <FAMILY HISTORY> Not relevant to presentation <PHYSICAL EXAM> ADMISSION VS: 98.3 84 107/68 18 100% Gen: Resting Pelvis: Multiple small papules bilaterally. Left labium majora erythematous and firm by 2 large abscess, one 4 x 1cm inferior and one 3 x 1cm superior indurated mass, no active drainage. Also noted is a 0.5 cm ulcerated lesion on the superior aspect of her right labium. A similar smaller lesion is seen inferiorly on the right. DISCHARGE VS: 97.6 102/64 63 16 98%RA Gen: Resting comfortably CV: Regular rate and rhythm Lungs: Clear to auscultation bilaterally Abdomen: soft, nontender, nondistended Pelvis: 2 areas of incision with wick extruding from L labium majus, 1 incision without wick on R labium majus. Some induration but no erythema or fluctuance. Ext: Nontender, no edema <MEDICATIONS ON ADMISSION> none <DISCHARGE MEDICATIONS> 1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation. Disp: *60 Capsule(s)* Refills: *0* 2. oxycodone-acetaminophen ___ mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain: do not take more than 4000mg acetaminophen (APAP) in 24hrs. Disp: *30 Tablet(s)* Refills: *0* 3. ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain: do not take more than 4 pills in 24hs. Disp: *30 Tablet(s)* Refills: *0* 4. clindamycin HCl 150 mg Capsule Sig: Three (3) Capsule PO Q8H (every 8 hours) for 14 days. Disp: *126 Capsule(s)* Refills: *0* 5. mupirocin calcium 2 % Cream Sig: One (1) Appl Topical BID (2 times a day) for 14 days. Disp: *1 tube* Refills: *0* 6. magnesium citrate Solution Sig: One (1) 300mg bottle PO once as needed for constipation: ___ repeat once if no bowel movement. Disp: *2 bottles* Refills: *0* <DISCHARGE DISPOSITION> Home With Service Facility: ___ <DISCHARGE DIAGNOSIS> labial abscess and cellulitis <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Dear Ms. ___, You were admitted after labial incision and drainage after a skin infection. It is very important that you take your antibiotics as directed. General instructions: * Take your medications as prescribed. * Do not drive while taking narcotics. * Narcotic medications can cause constipation. Please take a stool softener, such a colace, stay hydrated, and consume fiber. * No strenuous activity for 3 weeks. To reach medical records to get the records from this hospitalization sent to your doctor at home, call ___.
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Ms ___ was admitted following scheduled incision and drainage of her labial abscesses; please see operative report for full details of the procedure. Her labial packing was changed daily with 0.25" NuGauze and she was set up with an outpatient visiting nurse to assist with packing changes. She was begun on a course of clindamycin based on culture data from ___. She remained afebrile with adequate pain control, and was discharged home on postoperative day #2 voiding, ambulating, and tolerating a regular diet, with a visiting nurse and plan to follow up with Dr ___ at ___ ___ for close followup.
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11142612-DS-18
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___ <CHIEF COMPLAINT> spontaneous rupture of membranes <MAJOR SURGICAL OR INVASIVE PROCEDURE> cesarean section <HISTORY OF PRESENT ILLNESS> ___ G4P0 at 40w2d presenting with SROM with MEC at 1430 ___ with subsequent ctx q20min, regular, mild intensity. Denies VB. +FM. <PAST MEDICAL HISTORY> PNC: ___ ___ by U/S Labs O+/Abs-/RI/RPRNR/HBsAg-/HIV-/GBS- Declined genetic screening in setting of AMA -Screening FFS sig for low lying placenta. Tip of placenta touches but does not cross the internal os, consistent with marginal previa. EFW 50th% at 26w4d. Reevaluated at 33w2d found placenta 1.8cm from internal os, abutting posterior lip of cervix. -GLT nl Issues: -Marginal Previa -Anemia ___ Hgb 9.3 Hct 27.9% -Varicella Non-immune -Psychosocial stress: Previous husband committed suicide post adoption of daughter. Currently remarried. Victim of sexual trafficking as a child. OBHx: G4P0 1xTAB, 2xSAB GynHx: -no abnormal Pap -no fibroids PMH: -None PSH: -None <SOCIAL HISTORY> ___ <FAMILY HISTORY> noncontributory <PHYSICAL EXAM> (on admission) PE: 97.8, 86, 111/83 alert, comfortable Heart RRR Lungs CTAB abd soft, gravid, nontender EFW by ___: 7lbs Ext no calf tenderness SVE: ___ (1655) Toco: q2-3minutes FHT 135/mod var/+accels/-decels US: Vertex confirmed <PERTINENT RESULTS> ___ 09: 10PM BLOOD WBC-14.5* RBC-2.31* Hgb-7.9* Hct-22.6* MCV-98 MCH-34.3* MCHC-35.1* RDW-14.6 Plt ___ ___ 02: 18PM BLOOD WBC-14.6* RBC-2.24*# Hgb-7.6*# Hct-21.8*# MCV-97 MCH-33.7* MCHC-34.7 RDW-14.7 Plt ___ ___ 06: 36PM BLOOD WBC-16.8* RBC-3.42* Hgb-11.2* Hct-33.6* MCV-98 MCH-32.7* MCHC-33.3 RDW-14.8 Plt ___ ___ 02: 18PM BLOOD ___ PTT-28.4 ___ ___ 02: 18PM BLOOD ___ <MEDICATIONS ON ADMISSION> -PNV -iron <DISCHARGE MEDICATIONS> 1. Percocet ___ mg Tablet Sig: ___ Tablets PO every six (6) hours as needed for pain for 2 weeks. Disp: *40 Tablet(s)* Refills: *0* 2. Motrin 600 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for pain for 4 weeks. Disp: *40 Tablet(s)* Refills: *1* 3. Colace 100 mg Capsule Sig: One (1) Capsule PO three times a day as needed for constipation for 4 weeks. Disp: *60 Capsule(s)* Refills: *0* 4. ferrous gluconate 325 mg (37.5 mg Iron) Tablet Sig: One (1) Tablet PO three times a day. Disp: *90 Tablet(s)* Refills: *2* <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> term pregnancy s/p primary cesarean delivery of live female infant <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> routine PP/post-op instructions
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Ms. ___ was admitted ___ in labor. On ___, she had a cesarean delivery of a liveborn female infant (3420g, apgars 8 and 9) due to failed induction of labor. Please see operative note ___ for details. On post-op day 1, she had a single area of persistent bleeding in her incision (EBL 200cc), and she was taken back to the OR for re-exploration and excellent hemostasis was achieved. Please see operative report ___ for details. Her HCT pre-delivery was 33.6, which decreased to 21.8 before return to the OR, and this remained stable post-operatively at 22.6. The remainder of Ms. ___ postpartum course was uncomplicated. She had some subjective weakness, but otherwise had no symptoms of anemia. When offered the option of blood transfusion for her weakness, she opted for iron supplementation instead due to previous success with this method. By ___, Ms. ___ was ambulating without difficulty, voiding spontaneously, tolerating PO, had return of bowel function, her pain was well controlled, and she had no symptoms of anemia. She was then discharged home in good condition.
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11142615-DS-4
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> latex <ATTENDING> ___. <CHIEF COMPLAINT> low transverse cesarean section, wound infection with overlying cellulitis <MAJOR SURGICAL OR INVASIVE PROCEDURE> wound debridement <PHYSICAL EXAM> Physical Exam on Discharge: VS: Afebrile, VSS Neuro/Psych: NAD, Oriented x3, Affect Normal Heart: RRR Lungs: CTA b/l Abdomen: soft, appropriately tender, fundus firm, incision open and healing by secondary intention, no active draining or bleeding Pelvis: minimal bleeding Extremities: warm and well perfused, no calf tenderness, no edema <PERTINENT RESULTS> ___ 02: 45PM WBC-19.3*# RBC-3.68* HGB-9.6* HCT-29.7* MCV-81* MCH-26.1 MCHC-32.3 RDW-13.2 RDWSD-38.9 ___ 02: 45PM NEUTS-84.2* LYMPHS-6.4* MONOS-7.1 EOS-1.4 BASOS-0.3 IM ___ AbsNeut-16.22* AbsLymp-1.23 AbsMono-1.37* AbsEos-0.27 AbsBaso-0.06 ___ 02: 45PM PLT COUNT-261 ___ 02: 10PM UREA N-6 CREAT-0.6 ___ 02: 00PM URINE COLOR-Straw APPEAR-Clear SP ___ ___ 02: 00PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-TR ___ 01: 30PM VoidSpec-VOIDED ___ 08: 55AM ASCITES CREAT-0.5 ___ 08: 51AM URINE COLOR-Straw APPEAR-Clear SP ___ ___ 08: 51AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.5 LEUK-NEG ___ 08: 51AM URINE RBC-1 WBC-1 BACTERIA-NONE YEAST-NONE EPI-0 ___ 08: 51AM URINE MUCOUS-RARE <DISCHARGE INSTRUCTIONS> Dear Ms. ___, You were readmitted to the postpartum service for a wound infection in your C-section scar. You underwent debridement in the operating room and have had daily dressing changes. A home visiting nurse is being arranged for wound vac placement. Please continue taking your antibiotics, augmentin, at home until ___ While you were in the hospital you had a voiding cystogram which showed no leak in your bladder. Please follow up with urology as needed.
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On ___ Ms. ___ was admitted to the Postpartum service after undergoing a primary low transverse cesarean section and cystotomy repair. Her post-operative course was complicated by wound infection with overlying cellulitis. She had a leukocytosis and CT scan showed a 5x3x3cm fluid collection, likely seroma, fascia intact, with no evidence of pelvic abscess. She was stared on antibiotics and the following day On post-partum day 5, ___, she was taken to the operating room for wound debridement. Please see operative report for full details. She underwent dressing changes each day with a plan for wound vac placement after discharge. Wound culture preliminarily showed mixed bacterial flora, and sparse growth of Group C beta strep. She was seen by the Infectious Disease team who provided recommendations for her management. She was started on IV antibiotics (clindamycin and gentamicin, vancomycin), and transitioned to IV unasyn with plan for oral augmentin upon discharge. Her pain was controlled with IV dilaudid, Tylenol and toradol. For her cystotomy repair, her foley was kept in place for 7 days, and she underwent a cystogram which was normal. Her foley was then removed and she voided spontaneously. She had a UA which was negative for infection. By the day of discharge, she was afebrile with stable vital signs, and her pain was controlled with oral medications. She was then discharged home in stable condition, with outpatient follow-up the following day for ___ and office visit scheduled in one week Discharge Medications: 1. Acetaminophen 1000 mg PO Q6H 2. Amoxicillin-Clavulanic Acid ___ mg PO Q12H wound infection Duration: 17 Days RX *amoxicillin-pot clavulanate 875 mg-125 mg 1 tablet by mouth twice a day Disp #*34 Tablet Refills:*0 3. HYDROmorphone (Dilaudid) ___ mg PO Q3H RX *hydromorphone 2 mg ___ tablet(s) by mouth q 3hrs Disp #*144 Tablet Refills:*0 4. Ibuprofen 600 mg PO Q6H:PRN Pain - Mild RX *ibuprofen 600 mg 1 tablet(s) by mouth q6hours Disp #*60 Tablet Refills:*2 5. LORazepam 0.5 mg PO QHS:PRN anxiety RX *lorazepam 0.5 mg 1 tablet by mouth once a day Disp #*10 Tablet Refills:*0 6. Ondansetron 4 mg PO Q8H:PRN nausea Take if needed for nausea from antibiotics RX *ondansetron HCl 4 mg 1 tablet(s) by mouth every eight (8) hours Disp #*20 Tablet Refills:*2 Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: wound infection Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___
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11142882-DS-3
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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> s/p ureteroscopy ___ with stone removal left ureteral stent placement and removal <HISTORY OF PRESENT ILLNESS> ___ G2P1 at ___ with left lower quadrant pain since this AM. She reports it started in her left lower back and progressed to her LLQ. Pain is constant and has been worsening, does not come and go. No VB, LOF. Uncertain about FM as she has been in so much pain. BMs are normal. Had vomiting 2 days ago, no nausea/diarrhea. No abnormal vaginal discharge, lightheadedness/dizziness, fevers, chills. Nothing makes the pain better. In the ED, she received 8mg of morphine and 1mg of IV dilaudid with minimal relief. <PAST MEDICAL HISTORY> PNC: - ___ ___ by ___ - Labs Rh pos/Abs neg/Rub immune/RPRNR /HBsAg neg/HIV neg/GBS unknown - Screening LR panorama - FFS WNL - GLT WNL - Issues: * H/o gHTN, on ASA. no 24H baseline urine done. * IVF pregnancy OBHx: G2P1 - G1: SVD, c/b gHTN - G2: current GynHx: Denies h/o abnormal Pap, fibroids, Gyn surgery, STIs PMH: hypothyroidism PSH: appendectomy <SOCIAL HISTORY> ___ <FAMILY HISTORY> non-contributory <PHYSICAL EXAM> On admission: ___ 14: 15Resp.: 18 / min ___ 16: 42Temp.: 98.6°F ___ 16: 43BP: 115/55 (69) ___ ___: 87 Gen: A&O, comfortable Abd: soft, gravid, nontender. no rebound/guarding. SVE: FT at external os, closed at internal os, long, soft FHT 130/moderate variability/+accels/one decel at 16: 50 Toco: flat TAUS by ED: cephalic, FAST neg PUS ___: 1. There is oval echogenicity measuring 5 mm in diameter at the expected location of the left ureteral vesicular junction consistent with stone. Left hydronephrosis is better seen on the renal ultrasound from the same day. 2. Ovaries are not identified. 3. This exam was not tailored for evaluation of the fetus. Single live intrauterine pregnancy is noted. IMPRESSION: Mild left hydronephrosis. There is oval echogenicity measuring 5 mm enlarged diameter at the expected location of the left ureteral vesicular junction. On discharge: Vitals: T BP HR RR SpO2 97.8PO 102 / 62 68 18 97 RA Gen: [x] NAD Resp: [x] No evidence of respiratory distress Abd: [x] soft [x] non-tender Ext: [x] no edema [x] non-tender Date: ___ Time: 1315 FHT: 150/mod var/+accels/?slight variable deceleration, overall reassuring Toco: flat <PERTINENT RESULTS> ___ 12: 18PM BLOOD WBC-9.3 RBC-3.40* Hgb-10.5* Hct-31.0* MCV-91 MCH-30.9 MCHC-33.9 RDW-14.5 RDWSD-48.4* Plt ___ ___ 12: 18PM BLOOD Neuts-66.1 ___ Monos-5.2 Eos-1.0 Baso-0.2 Im ___ AbsNeut-6.12* AbsLymp-2.52 AbsMono-0.48 AbsEos-0.09 AbsBaso-0.02 ___ 05: 50AM BLOOD WBC-9.1 RBC-3.35* Hgb-10.3* Hct-30.8* MCV-92 MCH-30.7 MCHC-33.4 RDW-14.5 RDWSD-49.3* Plt ___ ___ 05: 50AM BLOOD Neuts-85.7* Lymphs-12.4* Monos-1.2* Eos-0.0* Baso-0.2 Im ___ AbsNeut-7.81* AbsLymp-1.13* AbsMono-0.11* AbsEos-0.00* AbsBaso-0.02 ___ 12: 18PM BLOOD ___ PTT-25.6 ___ ___ 12: 18PM BLOOD Glucose-109* UreaN-10 Creat-0.6 Na-137 K-4.0 Cl-104 HCO3-18* AnGap-19 ___ 05: 50AM BLOOD Creat-0.7 ___ 12: 18PM BLOOD ALT-15 AST-21 AlkPhos-63 TotBili-<0.2 ___ 12: 18PM BLOOD Albumin-3.4* UricAcd-4.6 ___ 01: 23PM BLOOD Lactate-1.2 ___ 02: 30PM URINE Blood-TR* Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG ___ 02: 30PM URINE RBC-5* WBC-1 Bacteri-FEW* Yeast-NONE Epi-2 TransE-<1 ___ 02: 30PM URINE Hours-RANDOM Creat-44 TotProt-14 Prot/Cr-0.3* ___ 06: 58AM URINE Hours-RANDOM Creat-36 TotProt-6 Prot/Cr-0.2 ___ 12: 50PM OTHER BODY FLUID STONE ANALYSIS-PND URINE CULTURE (Final ___: GRAM POSITIVE BACTERIA. >100,000 CFU/mL. Alpha hemolytic colonies consistent with alpha streptococcus or Lactobacillus sp. URINE CULTURE (Final ___: LACTOBACILLUS SPECIES. 1,000-10,000 CFU/ML. URINE CULTURE (Final ___: NO GROWTH. <MEDICATIONS ON ADMISSION> PNV, levothyroxine <DISCHARGE MEDICATIONS> 1. Acetaminophen ___ mg PO Q6H: PRN Pain - Mild Reason for PRN duplicate override: Alternating agents for similar severity RX *acetaminophen 500 mg ___ tablet(s) by mouth every six (6) hours Disp #*40 Tablet Refills: *0 2. Docusate Sodium 100 mg PO BID: PRN Constipation RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day Disp #*60 Capsule Refills: *2 3. Levothyroxine Sodium 100 mcg PO 2X/WEEK (___) 4. OxyCODONE (Immediate Release) ___ mg PO Q4H: PRN Pain - Moderate Reason for PRN duplicate override: Alternating agents for similar severity RX *oxycodone 5 mg ___ tablet(s) by mouth q4 hours Disp #*10 Tablet Refills: *0 5. Levothyroxine Sodium 50 mcg PO 5X/WEEK (___) <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> pregnancy at 27w4d L nephrolithiasis <DISCHARGE CONDITION> stable <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> You were admitted for management of a kidney stone. The urology team performed a ureteroscopy with stone removal and placed a left ureteral stent on ___. The following day, the stent was removed. It was felt it was safe for you to be discharged to home. You had no evidence of preterm labor and fetal testing was reassuring while you were here. You received a course of betamethasone for fetal lung maturity.
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___ G2P1 admitted at 27w2d with nephrolithiasis. She was afebrile and without any evidence of infection or preterm labor. A 5mm left UVJ stone was visualized on renal ultrasound. Urology was consulted and initially recommended conservative therapy with aggressive IV fluids and pain control. She continued to have significant pain on HD#2. The urology team spoke to her about options, and the decision was made to proceed with surgical management. She underwent cystoscopy, left ureteroscopy with basket extraction of the left ureteral stone, and placement of a temporary left ureteral catheter. The foley and stent were removed on POD#1 and her pain improved significantly. She was discharged to home and will have close follow up with urology in 2 weeks. . Of note, Ms ___ had reassuring fetal testing throughout this admission. She underwent prolonged monitoring on labor and delivery following the procedure in the operative room. She received a course of betamethasone for fetal lung maturity (complete ___ and the NICU was consulted.
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11143428-DS-7
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> fever, vaginal bleeding, abd pain, SOB <MAJOR SURGICAL OR INVASIVE PROCEDURE> Dilation and curettage blood transfusion <HISTORY OF PRESENT ILLNESS> ___ s/p IUFD and subsequent SVD on ___ presents with continued vaginal bleeding, abdominal pain, fever and shortness of breath. She notes continued vaginal bleeding since delivery, sometimes soaking through a heavy pad every 10 minutes. She thinks this has been worse over the course of the last day or two. She endorses feeling lightheaded and dizzy at home over the course of the day today. She endorses shortness of breath and difficulty taking a deep breath, as well as discomfort and tightness in the middle of her chest. Denies cough. She denies nausea or vomiting. Denies urinary symptoms. Denies diarrhea. ROS as per HPI, otherwise negative. <PAST MEDICAL HISTORY> OBHx: G5P2(1) - SVD x3 - TAB x2 GYNHx: - D&C x2 - Denies hx of STIs PMHx: - chronic hepatitis B ___: ALT26, AST22, HBcAb+, HAVAb+, HCVAb-, HBeAg -, HBeAb +, HBV VL not detected. On Viread 300mg QD) - positive PPD with negative CXR ___ PSHx: denies <SOCIAL HISTORY> ___ <FAMILY HISTORY> non-contributory <PHYSICAL EXAM> On admission: T99.7 HR 106 BP 148/88 RR20 98%onRA T100.2 HR 107 BP 152/83 RR20 98% onRA Gen: NAD, pale, lying in bed CV: tachycardic Pulm: breathing normally on RA Abd: soft, TTP in bilateral lower quadrants, +mild fundal tenderness SSE: deferred to OR Ext: mild edema of bilateral lower extremities, symmetric, no erythema or TTP On discharge General: NAD, A&Ox3 CV: RRR, normal S1/S2 without murmurs Lungs: CTAB, normal respiratory effort Abd: soft, nontender, fundus firm below umbilicus Lochia minimal Extremities: no calf tenderness, no edema <PERTINENT RESULTS> ___ 06: 35PM BLOOD WBC-18.3* RBC-3.05* Hgb-9.2* Hct-29.0* MCV-95 MCH-30.2 MCHC-31.7* RDW-13.7 RDWSD-46.5* Plt ___ ___ 11: 50PM BLOOD WBC-16.7* RBC-2.70* Hgb-8.2* Hct-25.5* MCV-94 MCH-30.4 MCHC-32.2 RDW-13.7 RDWSD-46.5* Plt ___ ___ 06: 33AM BLOOD WBC-11.4* RBC-2.18* Hgb-6.5* Hct-20.6* MCV-95 MCH-29.8 MCHC-31.6* RDW-13.6 RDWSD-46.3 Plt ___ ___ 12: 50PM BLOOD WBC-12.8* RBC-2.64* Hgb-7.9* Hct-24.4* MCV-92 MCH-29.9 MCHC-32.4 RDW-14.3 RDWSD-48.1* Plt ___ ___ 07: 15PM BLOOD WBC-12.0* RBC-2.68* Hgb-8.1* Hct-24.9* MCV-93 MCH-30.2 MCHC-32.5 RDW-14.6 RDWSD-48.9* Plt ___ ___ 12: 45AM BLOOD WBC-10.8* RBC-3.01* Hgb-8.8* Hct-27.1* MCV-90 MCH-29.2 MCHC-32.5 RDW-14.7 RDWSD-47.8* Plt ___ ___ 06: 35PM BLOOD Neuts-84.0* Lymphs-8.2* Monos-5.8 Eos-0.6* Baso-0.2 Im ___ AbsNeut-15.39* AbsLymp-1.50 AbsMono-1.07* AbsEos-0.11 AbsBaso-0.04 ___ 11: 50PM BLOOD Neuts-79.9* Lymphs-11.1* Monos-7.0 Eos-0.5* Baso-0.2 NRBC-0.1* Im ___ AbsNeut-13.36* AbsLymp-1.85 AbsMono-1.16* AbsEos-0.08 AbsBaso-0.03 ___ 06: 33AM BLOOD Neuts-75.7* Lymphs-13.9* Monos-8.3 Eos-0.9* Baso-0.1 Im ___ AbsNeut-8.59* AbsLymp-1.58 AbsMono-0.94* AbsEos-0.10 AbsBaso-0.01 ___ 06: 35PM BLOOD ___ PTT-26.3 ___ ___ 06: 35PM BLOOD Plt ___ ___ 11: 50PM BLOOD Plt ___ ___ 06: 33AM BLOOD Plt ___ ___ 12: 50PM BLOOD ___ PTT-26.4 ___ ___ 12: 50PM BLOOD Plt ___ ___ 07: 15PM BLOOD Plt ___ ___ 12: 45AM BLOOD Plt ___ ___ 06: 35PM BLOOD Glucose-100 UreaN-8 Creat-0.5 Na-142 K-4.0 Cl-113* HCO3-19* AnGap-10 ___ 12: 50PM BLOOD Glucose-91 UreaN-8 Creat-0.4 Na-137 K-3.9 Cl-109* HCO3-20* AnGap-8* ___ 12: 45AM BLOOD Creat-0.4 ___ 06: 35PM BLOOD ALT-219* AST-87* AlkPhos-98 TotBili-0.4 ___ 06: 33AM BLOOD ALT-151* AST-57* ___ 12: 45AM BLOOD ALT-86* AST-23 ___ 06: 35PM BLOOD Lipase-31 ___ 06: 35PM BLOOD cTropnT-<0.01 ___ 06: 35PM BLOOD Albumin-2.8* ___ 12: 50PM BLOOD Calcium-7.5* Phos-3.8 Mg-1.8 ___ 12: 45AM BLOOD UricAcd-5.1 ___ 06: 40PM BLOOD Lactate-1.1 ___ 6: 09 pm URINE - URINE CULTURE (Final ___: - MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION. ___: Lower extremity doppler ultrasound IMPRESSION: No evidence of deep venous thrombosis in the left lower extremity veins. ___: CTA Chest IMPRESSION: 1. No evidence of pulmonary embolism. No acute aortic pathology. 2. Mild pulmonary edema with small bilateral pleural effusions and dependent bilateral lower lobe atelectasis. 3. Multiple tiny nodular opacities within the left upper lobe suggests small airways disease, potentially infectious or inflammatory in etiology. 4. Multiple prominent right hilar and mediastinal nodes, likely reactive. ___: Transthoracic Echo IMPRESSION: Mildly dilated LA. Normal biventricular systolic function. Trace AR. Trace MR. ___ pulmonary HTN. Trace pericardial effusion. <MEDICATIONS ON ADMISSION> Meds: PNV, Viread daily <DISCHARGE MEDICATIONS> 1. Labetalol 300 mg PO TID RX *labetalol 100 mg 3 tablet(s) by mouth every eight (8) hours Disp #*180 Tablet Refills: *1 <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> Retained products of conception, s/p D&C Acute blood loss anemia, s/p blood transfusion Endometritis, s/p antibiotics Recent intrauterine fetal demise due to parvovirus infection <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Dear Ms. ___, You were admitted to the gynecology service 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. 1. Elevated Blood Pressures, con - You had elevated pressures while an inpatient. - Please continue labetalol 300mg three times daily until your next OB/GYN visit. - Please call if you experience any of the following: headache not resolved by Tylenol, vision changes, chest pain, shortness of breath. 2. Post dilation and curettage/ Endometritis - You underwent a dilation and curettage for your vaginal bleeding. You also received two units of packed red blood cells for your blood loss. At this time, you are no longer bleeding. Please call if you start to experience heavy vaginal bleeding. - You were found to have endometritis, which is an infection of your uterus. You were treated with IV antibiotics. 3. Transaminitis - You were found to have elevated liver enzymes while inpatient. These have decreased during your stay. We will continue to monitor you and your symptoms closely. - Please call if you start to experience any right sided upper abdominal pain. General instructions: * Take your medications as prescribed. * 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
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Ms. ___ is a ___ year old G5P2(1) with a recent vaginal delivery after induction of labor for intrauterine fetal demise on ___ who was re-admitted to the gynecology service on ___ with endometritis and retained products of conception necessitating ultrasound guided dilation and curettage on ___. Her post op course was complicated by acute blood loss anemia requiring transfusion, as well as transaminitis of unknown etiology, and elevated severe range blood pressures concerning for atypical severe pre-eclampsia. On ___, patient underwent a dilation and curettage for retained products of conception. Her blood loss was 100cc in the case and then upon arriving to the floor, she was noted to have another 300cc blood loss. She had received cytotec and hemabate. Her hematocrit was trended and she was noted to have a decreased to 20.6 from 29. She was thus transfused 2 units of packed red blood cells. Her coagulation panel was normal. Her electrolytes were normal. Her bleeding stopped and her hematocrit was improved to 24.9 on ___ and 27.1 on ___. Patient was also started on ampicillin, gentamicin and clindamycin for treatment of her endometritis. She was afebrile throughout the rest of her ___ hospital admission. Of note, on admission, patient was noted to have a transaminitis with an ALT/AST of 218/87. This downtrended to ___ on ___. She was noted to have elevated bile acids on ___ as well. This transaminitis was attributed to possible cholestasis of pregnancy. She was also continued on tenofovir for her chronic hepatitis B, which was deemed as an unlikely cause of her transaminitis given her previously normal liver function tests on ___. On ___, patient was noted to have elevated blood pressures to severe ranges. She was started on nifedipine 30mg daily. However, given a large decrease in her blood pressures and overall dizziness, her regimen was switched to labetalol 100mg twice daily. This was changed to 200mg twice daily on ___ and 200mg three times a day on ___ due to persistent elevated BPs. Pregnancy induced hypertension labs on ___ were sent. She was found to have a downtrending transaminitis from that which she initially arrived with. Blood pressures appeared to stabilize on labetolol 200mg 3 times a day on day of discharge. Patient's placental pathology did test positive for parvovirus and there was concern for possible parvovirus related cardiomyopathy. Patient thus underwent a transthoracic echo on ___. This returned overall within normal limits. At that point, patient had improved blood pressures and was able to ambulate, eat, void without issue. She no longer had any vaginal bleeding and she had no new febrile episodes. She was thus discharged to home with close follow up.
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11146717-DS-19
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Penicillins <ATTENDING> ___. <CHIEF COMPLAINT> Fibroid uterus <MAJOR SURGICAL OR INVASIVE PROCEDURE> Abdominal supracervical hysterectomy, cystoscopy <HISTORY OF PRESENT ILLNESS> This is a ___ gravida 0 with a history of symptomatic fibroid uterus. The patient had undergone uterine artery embolization many years prior as well as an abdominal myomectomy. However, her fibroids returned and became symptomatic with pelvic pressure and menometrorrhagia. Given her symptoms, the patient decided to proceed with definitive surgical management via a hysterectomy. She was counseled regarding the risks and benefits of a supracervical and a total hysterectomy and the patient opted for an abdominal supracervical hysterectomy. Informed consent was obtained prior to proceeding to the operating room. <PAST MEDICAL HISTORY> PMH: hyperthyroid PSH: UAE, abd MMY <SOCIAL HISTORY> ___ <FAMILY HISTORY> Non-contributory <PHYSICAL EXAM> Discharge exam: VSS Gen: Well NAD Card: RRR Resp: CTAB Abd: soft, NT, ND, vertical midline incision c/d/i Pelvic: No VB Ext: NT, NE <PERTINENT RESULTS> None <MEDICATIONS ON ADMISSION> Levoxyl 75' <DISCHARGE MEDICATIONS> 1. oxycodone-acetaminophen ___ mg Tablet Sig: ___ Tablets PO Q4H (every 4 hours) as needed for pain. Disp: *50 Tablet(s)* Refills: *0* 2. ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. Disp: *50 Tablet(s)* Refills: *1* 3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp: *60 Capsule(s)* Refills: *2* 4. levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> Fibroid uterus <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Please call your doctor or return to the hospital if you have: -Increased pain -Redness or unusual discharge from your incision -Inability to eat or drink because of nausea and/or vomiting -Fevers/chills -Chest pain or shortness of breath -Any other questions or concerns Other instructions: -You should not drive for 2 weeks and while taking narcotic pain medications -No intercourse, tampons, or douching for 6 weeks -No heavy lifting or vigorous activity for 6 weeks -You can shower and clean your wound, but do not use perfumed soaps or lotions. Be sure to pat completely dry after washing. -You may resume your regular diet and home medications.
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Ms. ___ was admitted to the GYN service after undergoing abdominal supracervical hysterectomyand cystoscopy. Please see Dr. ___ report for full details of her procedure. Post-oeratively, she did well without complication. She was discharged on POD#2 at which time she was tolerating a regular diet, ambulating, and voiding independently. Her pain well was well controlled on oral pain medications at the time of discharge.
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| 91
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11147761-DS-14
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Penicillins / Percocet <ATTENDING> ___ <CHIEF COMPLAINT> transfer from ___ for elevated blood pressures and decels with mild contractions <MAJOR SURGICAL OR INVASIVE PROCEDURE> repeat classical cesarean section <HISTORY OF PRESENT ILLNESS> ___ yo G7P3 @ ___ who initially presented to OSH on ___ with contractions every ___ minutes. Contractions spaced however blood pressures elevated (max 179/115) and complained of chronic but worse headaceh. She required 2 doses of IV labetalol which brought her BP to 110-130/60-70's and subsequently she was started on PO labetalol. Her labs were normal except for a mild thrombocytopenia (plts 144). She remained on the antepartum service at ___ until this morning when she again had mild contractions associated with FHR decelerations. At that time she was started on magnesium with resolution of contractions/ decels and transferred to ___. She was made BMZ complete at OS___. Currently, Ms. ___ HA (frontal and occipital). Similar to prior HA which she has had daily in this pregnancy however currently a little worse. No visual changes. No epigastric discomfort. No CP, SOB. <PAST MEDICAL HISTORY> PNC: - ___ ___ - A+, ab neg, HBsAg neg, Rub ___, RPR NR, GBS unk - GLT wnl - ERA low risk, FFS wnl, ant placenta - EFW 1181g 42% (___) - issues: * AMA * intermittently elevated BP's (130/90's @ 14wks), OBhx: - LTCS x 3, ___ for breech, ___ for failed TOL, ___ sched repeat, all deliveries at term. Elevated BP in preg with ___ pregnancy however no comp in others. - SAB x 4 PMH: -? borderline HTN, no meds PSH: - 3 x LTCS - D&C x 1 <SOCIAL HISTORY> ___ <FAMILY HISTORY> non-contributory <PHYSICAL EXAM> (on admission) T 97.8, HR 88, BP 154/95 (140-154/77-100), RR 20 UOP >100/ hour NAD, sleepy RRR, no m/r/g CTAB Abd gravid, NT Ext NT/NE foley with clear yellow urine BPP: ___ (-2 breathing), vtx, ant placenta, AFI 12 <PERTINENT RESULTS> ___ WBC-11.4 RBC-4.07 Hgb-12.9 Hct-37.8 MCV-93 Plt-187 ___ WBC-12.9 RBC-3.89 Hgb-12.3 Hct-36.5 MCV-94 Plt-161 ___ WBC-11.2 RBC-3.86 Hgb-12.0 Hct-36.6 MCV-95 Plt-186 ___ ___ PTT-22.4 ___ ___ ___ PTT-19.5 ___ ___ Creat-0.6 ALT-10 UricAcd-5.1 ___ Creat-0.7 ALT-10 UricAcd-5.2 LD(LDH)-162 ___ Creat-0.5 ALT-12 UricAcd-4.7 ___ Creat-0.8 ALT-11 UricAcd-5.8 ___ BLOOD Hapto-141 ___ URINE Blood-TR Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG ___ URINE RBC-3 WBC-<1 Bacteri-NONE Yeast-NONE Epi-<1 ___ URINE Hours-RANDOM Creat-45 TotProt-12 Prot/Cr-0.3 ___ URINE Hours-RANDOM Creat-78 TotProt-20 Prot/Cr-0.3 <MEDICATIONS ON ADMISSION> none <DISCHARGE MEDICATIONS> 1. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for Pain for 10 days. Disp: *60 Tablet(s)* Refills: *0* 2. Labetalol 200 mg Tablet Sig: Three (3) Tablet PO TID (3 times a day). Disp: *100 Tablet(s)* Refills: *2* 3. Hydrocodone-Acetaminophen ___ mg Tablet Sig: ___ Tablets PO every ___ hours as needed for pain for 10 days. Disp: *40 Tablet(s)* Refills: *0* 4. Nifedipine 30 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO BID (2 times a day) for 10 days. Disp: *40 Tablet Sustained Release(s)* Refills: *1* <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> Severe preeclampsia Delivery at 29wks <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Given See below BP monitor 3x per day Continue taking medications as prescribed.
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Ms ___ is a ___ y/o G7P3 with suspected chronic hypertension admitted at 29+4 weeks gestation with intermittent decels, mild contractions and concern for superimposed preeclampsia. Her blood pressures were 140-154/77-100 on arrival. Preeclampsia labs were significant for an elevated urine protein/creatinine ratio (0.3). She was continued on labetolol (200mg tid) and closely observed. Fetal testing was overall reassuring and she was already betamethasone complete. The NICU was consulted. The 24 hour urine collection at ___ had 324mg of protein, confirming the diagnosis of preeclampsia. On HD#2, her blood pressures became quite elevated and she was sent to labor and delivery for management of her hypertensive urgency (BPs up to 200s/100s). She received IV hydralazine (total 15mg) and her BPs improved to 150s/80s. Preeclampsia labs were stable and fetal testing was reassuring. The labetolol was increased to 600mg tid. However, her BPs again climbed to 190s/100 and she received an additional dose of IV Hydralazine. At that time, the decision was made to proceed with delivery. She had a repeat classical cesarean section on ___ (at 29+4 weeks). Liveborn male with apgars of 7 and 8. Weight unknown at the time of delivery. NICU was present for delivery and transferred the neonate immediately for prematurity. Please see operative note for details. . Postpartum, she received Magnesium for seizure prophylaxis for 24 hours. Her repeat HELLP labs were within normal limits except an elevated uric acid of 5.8. Initially her blood pressures were well controlled in the 130-140s/80s range on Labetalol 200 BID. However, on POD#1 her blood pressures trended up to the 160s/90s and her Labetalol was titrated up to 600 mg PO TID. Her blood pressures were not responsive to increased doses of Labetalol. She was then started on Nifedepine 30 mg CR Daily with good result. On POD#3, her blood pressures again trended up to the 160/90-100 range and her Nifedipine was increased to 30 mg CR PO twice daily, with good result. She was discharged on Labetalol 600 mg PO TID and Nifedipine 30 mg CR PO BID. Throughout her hospitalization she denied symptoms of pre-eclampsia. She was discharged home in stable condition on POD#4.
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| 578
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11150857-DS-2
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___ <CHIEF COMPLAINT> postpartum severe preeclampsia <MAJOR SURGICAL OR INVASIVE PROCEDURE> None <HISTORY OF PRESENT ILLNESS> ___ yo ___ s/p SVD on ___ who presents to ___ ED as a transfer from ___ ED with concern for post partum pre-eclampsia given severe range blood pressures and persistent headache. The patient had an uncomplicated vaginal delivery on ___ with an uncomplicated post partum course. She reports a new onset posterior headache starting three days ago. She notes seeing intermittent black and white spots, increasing in frequency over the last three days. Her headache became progressively worse over the course of the last three days, prompting her presentation to the ED. Per the transfer documentation from ___, she was found to be hypertensive to the 200's/100's. She was given 10mg IV labetalol, started on magnesium with a 6gm bolus -> 2gm/hr maintenance rate, 15mg IV toradol and 4mg morphine. She underwent a non-contrast CT of her head, which was negative for acute intracranial processes or hemorrhage. ___ labs were all WNL. She reported mild improvement in her headache, then was transferred to ___ for further management. Here, she notes evolution of her headache from the back of her head to the front of her head, now with worsening visual symptoms. She felt like she was just "seeing spots" before, but now she states she is unable to see her phone to type or focus long enough to participate in a neurological exam. She denies chest pain or shortness of breath, denies upper abdominal pain or new swelling of her extremities. She denies abdominal cramping, her lochia is minimal requiring ___ pads per day. She has been breastfeeding. Her newborn son is doing well and is currently being cared for by the father of the baby. She is noticeably concerned and agitated by her current visual symptoms. <PAST MEDICAL HISTORY> ___: - ___ -3 TAB (___) for undesired pregnancy -NSVD x 3 ___ no hx of pre-eclampsia or HTN disorders; most recent SVD uncomplicated at term GynHx: -History of +HPV ___ -Denies history of fibroids -D&C x 2 -H/o Chlamydia ___ PMH: - Congenital Heart Defect, repaired at birth. - Depression (previously on Prozac and Ativan prior to pregnancy) PSH: -congenital cardiac surgery (further details unknown to patient and not available) -D&C x 2 <PHYSICAL EXAM> Physical Exam on Discharge: VS: Afebrile, VSS Neuro/Psych: NAD, Oriented x3, Affect Normal Heart: RRR Lungs: CTA b/l Abdomen: soft, appropriately tender, fundus firm Pelvis: minimal bleeding Extremities: warm and well perfused, no calf tenderness, no edema <PERTINENT RESULTS> --===== Labs --===== ___ 06: 34AM BLOOD WBC-6.6 RBC-4.19 Hgb-13.0 Hct-39.2 MCV-94 MCH-31.0 MCHC-33.2 RDW-15.1 RDWSD-52.5* Plt ___ ___ 09: 30AM BLOOD WBC-7.9 RBC-3.95 Hgb-12.6 Hct-37.3# MCV-94 MCH-31.9 MCHC-33.8 RDW-15.0 RDWSD-52.3* Plt ___ ___ 09: 30AM BLOOD Neuts-56.5 ___ Monos-7.9 Eos-2.5 Baso-0.5 Im ___ AbsNeut-4.47 AbsLymp-2.50 AbsMono-0.63 AbsEos-0.20 AbsBaso-0.04 ___ 09: 30AM BLOOD ___ PTT-28.1 ___ ___ 06: 34AM BLOOD Glucose-93 UreaN-17 Creat-0.7 Na-140 K-4.3 Cl-105 HCO3-22 AnGap-17 ___ 09: 30AM BLOOD Glucose-104* UreaN-7 Creat-0.6 Na-138 K-3.4 Cl-104 HCO3-20* AnGap-17 ___ 06: 34AM BLOOD ALT-32 AST-21 ___ 09: 30AM BLOOD ALT-29 AST-21 AlkPhos-108* TotBili-0.2 ___ 06: 34AM BLOOD Calcium-9.3 Phos-4.2 Mg-1.7 Cholest-209* ___ 09: 35AM BLOOD %HbA1c-5.0 eAG-97 ___ 06: 34AM BLOOD Triglyc-221* HDL-57 CHOL/HD-3.7 LDLcalc-108 ___ 09: 35AM URINE Color-Straw Appear-Clear Sp ___ ___ 09: 35AM URINE Blood-MOD Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.5 Leuks-SM ___ 09: 35AM URINE RBC-2 WBC-8* Bacteri-NONE Yeast-NONE Epi-2 TransE-<1 ___ 07: 32PM URINE bnzodzp-NEG barbitr-NEG opiates-NEG cocaine-NEG amphetm-NEG mthdone-NEG --===== Microbiology --===== ___ 9: 35 am URINE **FINAL REPORT ___ URINE CULTURE (Final ___: MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION. --===== Imaging --===== MRI/MRV Head (___) 1. There are punctate periventricular and subcortical T2/FLAIR nonenhancing white matter hyperintensities nonspecific in a patient of this age, however not in a distribution typical for PRES. Differential considerations include sequela of chronic headache such as migraine, prior trauma, infectious/inflammatory etiology or small vessel ischemic disease. 2. No acute infarct or intracranial hemorrhage. 3. The dural venous sinuses are patent on MP-RAGE and MRV. Echocardiography (___) The left atrium and right atrium are normal in cavity size. No atrial septal defect is seen by 2D or color Doppler. The estimated right atrial pressure is ___ mmHg. There is mild symmetric left ventricular hypertrophy with normal cavity size and global systolic function (LVEF>55%). Doppler parameters are most consistent with normal left ventricular diastolic function. Right ventricular chamber size and free wall motion are normal. The diameters of aorta at the sinus, ascending and arch levels are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis or aortic regurgitation. The mitral valve leaflets are mildly thickened. The mitral valve leaflets are myxomatous. There is no mitral valve prolapse. No mitral regurgitation is seen. The estimated pulmonary artery systolic pressure is normal. Renal artery Doppler (___) Normal renal ultrasound. No evidence of renal artery stenosis. <DISCHARGE INSTRUCTIONS> You are leaving against medical advice. Check you BPs daily and do not take BP medication if you feel dizzy of blood pressure is below 120/70. ___ will come to your house to check your blood pressure. Follow-up in our clinic on ___ or ___ to check-in. Cardiology will call you to make an appointment for follow-up.
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On ___, Ms. ___ was readmitted to the postpartum service for severe postpartum preeclampsia. Given her headache and visual disturbances, neurology was consulted. They recommended imaging. She had a MRI/MRV which showed no acute infarct or intracranial hemorrhage and no evidence of venous sinus thrombosis or PRES. It was felt that her headaches were secondary to her hypertension. She continued to have headaches which responded to compazine, toradol and fioricet. For her preeclampsia, she received 24 hours of magnesium. On HD#2 she started having severe range blood pressures and was started on labetalol 200mg BID. Her medications were titrated daily due to labile blood pressures despite labetalol 600mg q8h and hydralazine 10mg q6h. Given persistence of severe range BP, medicine was consulted for further management. They recommended renal ultrasound, ECHO and labs all of which were normal. With additional severe range BP her regimen was changed to labetalol 800mg q8h and captopril 25mg BID. Patient was advised to remain in house for monitoring but elected to leave against medical advice. Visiting nurse was arranged for at home BP monitoring as well as outpatient postpartum and cardiology appointments. Preeclampsia signs were reviewed prior to discharge. Discharge Medications: 1. Acetaminophen-Caff-Butalbital ___ TAB PO Q6H:PRN Pain - Moderate Reason for PRN duplicate override: Alternating agents for similar severity 2. Blood Pressure Kit (blood pressure monitor) 1 medical supply Q6H check q6 hours RX *blood pressure monitor [Blood Pressure Kit] use as directed every six (6) hours Disp #*1 Kit Refills:*0 3. Captopril 25 mg PO BID RX *captopril 25 mg 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*1 4. Docusate Sodium 100 mg PO BID:PRN Constipation RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice a day Disp #*60 Capsule Refills:*0 5. HydrALAZINE 10 mg PO Q6H RX *hydralazine 10 mg 1 tablet(s) by mouth every six (6) hours Disp #*120 Tablet Refills:*1 6. Ibuprofen 600 mg PO Q6H:PRN Moderate Pain RX *ibuprofen 600 mg 1 tablet(s) by mouth every six (6) hours Disp #*25 Tablet Refills:*0 7. Labetalol 800 mg PO Q8H RX *labetalol 200 mg 4 tablet(s) by mouth three times a day Disp #*360 Tablet Refills:*3 8. Prochlorperazine 10 mg PO Q6H:PRN headache RX *prochlorperazine maleate 10 mg 1 tablet(s) by mouth every six (6) hours Disp #*40 Tablet Refills:*0 Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Preeclampsia post partum Hypertension Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___
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11159682-DS-17
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___ <CHIEF COMPLAINT> left flank pain <MAJOR SURGICAL OR INVASIVE PROCEDURE> none <HISTORY OF PRESENT ILLNESS> ___ G7P1 at 22w2d with new onset left sided flank pain. She states the pain began around 3pm this afternoon. She also noted radiation to her groin and back. She endorses pain through her abdomen and some mild nausea. She presented to ___ for evaluation where she was found to have left sided hydronephrosis on ultrasound. She received 6 mg total of IV morphine for pain control, the last at 2200. She states the IV pain meds helped her pain improve from ___ to ___. On transfer to ___ she had worsening nausea with 300cc of emesis. On evaluation here, she denies ctx, VB, LOF. Endorses active fetal movement. Continues to have left sided pain and discomfort with pain radiating to groin. She denies fevers or chills. No issues initiating urine stream or dysuria. <PAST MEDICAL HISTORY> PNC: - ___ ___ by first trimester ultrasound - Labs O pos /Abs neg /Rub /RPR /HBsAg neg/HIV neg/GBS unknown - Screening : low risk ERA - FFS: normal - GTT: n/a - U/S - Issues *)H/o MVA with 12 fractures and chronic pain: on Tylenol *)H/o bipolar disorder/PTSD: followed by Dr. ___ at OB ___, currently on olanzapine and trazadone prn *)Interval prenatal care: has not been to primary OB since ___ weeks OBHx: G7P1 - 1 SVD - 4 SAB - 1 ectopic GynHx: - denies abnormal Pap or cervical procedures - denies STIs, including HSV - h/o endometriosis s/p diagnostic laparoscopy PMH: endometriosis, PTSD, anxiety, bipolar disorder, asthma, h/o MVA with multiple fractures requiring ___ rehab PSH: diagnostic laparoscopy x2, D&C x12 <SOCIAL HISTORY> endorses marijuana use, denies alcohol or cigarette use <PHYSICAL EXAM> Physical Exam on Discharge: CONSTITUTIONAL: normal HEENT: normal, MMM NEURO: alert, appropriate, oriented x 4 RESP: no increased WOB HEART: extremities warm and well perfused ABDOMEN: gravid, non-tender EXTREMITIES: non-tender, no edema FHR: present at a normal rate <PERTINENT RESULTS> ___ 11: 31PM URINE bnzodzpn-NEG barbitrt-NEG opiates-POS* cocaine-NEG amphetmn-NEG oxycodn-NEG mthdone-NEG ___ 11: 31PM URINE COLOR-Straw APPEAR-Hazy* SP ___ ___ 11: 31PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR* GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-SM* ___ 11: 31PM URINE RBC-1 WBC-9* BACTERIA-FEW* YEAST-NONE EPI-16 ___ 11: 31PM URINE MUCOUS-RARE* ___ 10: 50PM GLUCOSE-81 UREA N-7 CREAT-0.4 SODIUM-136 POTASSIUM-3.8 CHLORIDE-104 TOTAL CO2-19* ANION GAP-13 ___ 10: 50PM estGFR-Using this ___ 10: 50PM CALCIUM-8.0* PHOSPHATE-3.4 MAGNESIUM-1.6 ___ 10: 50PM PLT COUNT-166 <MEDICATIONS ON ADMISSION> PNV, olanzapine 5mg prn, trazadone 50mg qhs <DISCHARGE MEDICATIONS> 1. Docusate Sodium 100 mg PO BID: PRN Constipation RX *docusate sodium 100 mg 1 capsule(s) by mouth twice daily Disp #*50 Capsule Refills: *0 2. HYDROmorphone (Dilaudid) 2 mg PO Q4H: PRN Pain - Severe Reason for PRN duplicate override: d/c'ing oxy Do not drink alcohol or drive. RX *hydromorphone [Dilaudid] 2 mg 1 tablet(s) by mouth every 4 hours Disp #*30 Tablet Refills: *0 3. Ondansetron ___ mg PO Q8H: PRN nausea RX *ondansetron 4 mg 1 tablet(s) by mouth every eight (8) hours Disp #*8 Tablet Refills: *0 4. Prenatal Vitamins 1 TAB PO DAILY <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> kidney stones <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Dear. Ms. ___, You were admitted to the hospital with kidney stones. You were monitored and passed multiple kidney stones. All of your fetal testing have been reassuring. We think it is now safe for you to go home. Please follow the instructions below: - Continue to hydrate - 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. ___ was transferred to the ___ service for left sided flank pain concerning for nephrolithiasis. She was given IV Tylenol and Dilaudid PCA initially for pain management. She had normal labwork, and was also given Zofran for nausea. She underwent a renal ultrasound which showed mild right hydronephrosis, and no nephrolithiasis. She underwent fetal heart rate checks which were all in normal range. During the course of her admission, she passed multiple small stones. Her pain improved and she was transitioned to oral pain meds, and she tolerated a regular diet with minimal nausea. She was discharged home in stable condition with outpatient follow-up scheduled.
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11161856-DS-17
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> amoxicillin <ATTENDING> ___. <CHIEF COMPLAINT> Abdominal pain <MAJOR SURGICAL OR INVASIVE PROCEDURE> Laparoscopic de-torsion of left adnexa, left ovarian cystectomy, left tubal cystectomy <HISTORY OF PRESENT ILLNESS> Ms. ___ is a ___ G0 with a history of one day of LLQ pain, OB/GYN was consulted for evaluation for rule out torsion. Last night she developed LLQ pain. Pain accompanied by nausea and 3 episodes of emesis. She also reports lightheadedness and dizziness. Pain is intermittent. When it is present rates at ___. In between she feels a dull ache. Pain increases w/ ambulation. At home she has taken Tylenol for the pain. GYN history significant for ovarian and tubal cysts. Patient followed by OSH gynecologist for management. Recommended surgery but cysts decreased in size so it was deferred. <PAST MEDICAL HISTORY> PMH: herniated disks in neck, h/o concussions, shoulder separation PSH: denies OBHx: G0 GYNHx: - h/o CT s/p Rx - LMP: beginning of ___, takes OCPs consistently - h/o of cysts on both ovaries, fallopian tube - denies abnormal Pap, fibroids, gyn surgery <PHYSICAL EXAM> CV: RRR, no m/r/g Pulm: CTAB, no crackles or wheezes appreciated Abd: soft, appropriately tender. 4 port site dressings c/d/I, no rebound or guarding GU: pad with minimal spotting Ext: WWP no tenderness or erythema bilaterally <PERTINENT RESULTS> ___ 01: 00PM BLOOD WBC-7.7 RBC-4.53 Hgb-13.8 Hct-40.3 MCV-89 MCH-30.5 MCHC-34.2 RDW-12.5 RDWSD-40.8 Plt ___ ___ 01: 00PM BLOOD Neuts-77.3* Lymphs-18.3* Monos-3.8* Eos-0.0* Baso-0.3 Im ___ AbsNeut-5.92 AbsLymp-1.40 AbsMono-0.29 AbsEos-0.00* AbsBaso-0.02 ___ 01: 00PM BLOOD Glucose-88 UreaN-12 Creat-0.7 Na-139 K-5.6* Cl-103 HCO3-22 AnGap-14 <MEDICATIONS ON ADMISSION> None <DISCHARGE MEDICATIONS> 1. Acetaminophen ___ mg PO Q6H: PRN Pain - Mild Do not exceed 4000mg in 24 hours RX *acetaminophen 500 mg ___ tablet(s) by mouth q6h prn pain Disp #*60 Tablet Refills: *0 2. Docusate Sodium 100 mg PO BID: PRN constipation RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day Disp #*40 Capsule Refills: *1 3. Ibuprofen 600 mg PO Q6H: PRN Pain - Mild Reason for PRN duplicate override: Alternating agents for similar severity Take with food. RX *ibuprofen 600 mg 1 tablet(s) by mouth q6h prn Disp #*60 Tablet Refills: *0 4. OxyCODONE (Immediate Release) 5 mg PO Q4H: PRN Pain - Severe may cause dizziness, 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> Ovarian torsion <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Dear Ms. ___, You were admitted to the 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. * 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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Ms. ___ was admitted to the gynecology service after undergoing a laparoscopic detorsion of left adnexa, left ovarian cystectomy, and left tubal cystectomy for ovarian torsion. Her postoperative course was uncomplicated. Her pain was controlled on oral acetaminophen, ibuprofen, and oxycodone. By postoperative day 1, she was tolerating a regular diet, voiding spontaneously, and ambulating. She was discharged home with close follow-up.
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11164150-DS-10
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Patient recorded as having No Known Allergies to Drugs <ATTENDING> ___. <CHIEF COMPLAINT> Incisional drainage <MAJOR SURGICAL OR INVASIVE PROCEDURE> Incision and drainage of c-section incision <HISTORY OF PRESENT ILLNESS> The patient is a ___ year-old gravida 1 para 1 who underwent a low transverse cesarean section on ___ at 40 weeks gestational age for non-reassuring fetal heart tracing in the face of chorioamnionitis and pushing. During the immediate pospartum period, she was treated with ampicillin, gentamicin and clindamicin until 48 hours afebrile. Her initial anaerobic blood culture grew gram negative rods identified as Prevotella and presumptive Gardnerella species, but all other blood and urine cultures were negative. She remained afebrile and was discharged home on post-operative day #5 off antibiotics. The patient presented to the emergency department on post-operative day #9 (___) complaining of yellow drainage from her incision beginning at 11pm the night prior. She had pain at the incision relieved by percocet and motrin. She denied fevers and chills to one interviewer, but to the infectious disease consult reported high subjective fevers and chills nightly with no drenching night sweats. She denied nausea, vomiting and diarrhea. <PAST MEDICAL HISTORY> Obstetrical history: Gravida 1 Para 1 - primary low transverse cesarean section on ___ Gynecologic history: ___ history: denies Surgical history: appendectomy age ___ <SOCIAL HISTORY> ___ <FAMILY HISTORY> Noncontributory <PHYSICAL EXAM> Admission physical exam (per Dr. ___ 99.3 28 120/79 99% Room Air (Respiratory Rate on my exam was 16) No acute distress Regular rate and rhythm Clear to auscultation bilaterally Abdomen soft, nontender, nondistended Incision: draining yellow purulent fluid from mid incision, incision with surrounding erythema, no induration, mildly tender Ext nontender Infectiousl disease consult physical exam on hospital day #1 (per Dr. ___ T-98.4, P-76, R-16, BP-118/70 General: pleasant, non-toxic, no distress, slightly anxious HEENT: no frontal or maxillary sinus tenderness; conjunctivae clear, sclerae anicteric; OP clear; MMM Neck: soft and supple Cardiovascular: RRR, normal S1 and S2, II/VI HSM along the left sternal border, no r/g Respiratory: CTA bilaterally posteriorly Back: mild tenderness over the lumbar spine, o/w spinal or paraspinal tenderness Gastrointestinal: soft, non-distended, active bowel sounds; diffuse hypogastric tenderness Genitourinary: no CVA tenderness Musculoskeletal: no ___ edema Skin: horizontal cesarean section incision is open and packed with damp gauze; there is a 1.5 cm margin of erythema over the superior margin of the wound, and a 1 cm margin of erythema over the inferior margin; there is induration but no fluctuance diffusely around the perimeter of the incision; there is no active drainage from the incision; there is diffuse tenderness around the perimeter of the incision Neurological: alert, appropriate Heme/Lymph: no cervical, supraclavicular, preauricular, occipital, or inguinal lymphadenopathy <PERTINENT RESULTS> White blood count: 17.3 (84% PMNs, 0 bands) -> 13.6 (81% PMNs, 0 bands) -> 11.0 (75% PMNs, 0 bands) -> 10.1 -> 8.6 -> 7.8 -> 6.3 -> 5.0 -> 6.2 . Platelets: 792 -> 935 -> 991 -> 1109 -> 1129 -> 1017 -> 948 -> 700 -> 596 -> 568 . ALT: ___ AST: ___ Alk Phos: 107-129 LDH: 259 Cr: 0.7 - 1.1 . Clostridium Difficile toxin assay negative x 3 . Blood cultures x 2 (___): No growth Blood cultures x 2 (___): pending Urine culture (___): No growth . ___ 1: 15 am SWAB Site: ABDOMEN ABDOMEN WOUND. GRAM STAIN (Final ___: 3+ ___ per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. 4+ (>10 per 1000X FIELD): GRAM NEGATIVE ROD(S). SMEAR REVIEWED; RESULTS CONFIRMED. WOUND CULTURE (Final ___: Due to mixed bacterial types ( >= 3 colony types) an abbreviated workup is performed appropriate to the isolates recovered from the site (including a screen for Pseudomonas aeruginosa, Staphylococcus aureus and beta streptococcus). Susceptibility will be performed on P. aeruginosa and S. aureus if sparse growth or greater. ANAEROBE IDENTIFIED PER D. ___ ___. PREVOTELLA SPECIES. SPARSE GROWTH. BETA LACTAMASE POSITIVE. . ___ 2: 07 pm SWAB Site: ABDOMEN Source: abdominal wound. GRAM STAIN (Final ___: 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. WOUND CULTURE (Final ___: STAPHYLOCOCCUS, COAGULASE NEGATIVE. SPARSE GROWTH. CORYNEBACTERIUM SPECIES (DIPHTHEROIDS). RARE GROWTH. ANAEROBIC CULTURE (Final ___: NO ANAEROBES ISOLATED. . CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST (___) CT OF THE ABDOMEN WITH IV CONTRAST: The visualized lung bases are clear. The liver, gallbladder, pancreas, spleen, adrenal glands, kidneys, and unopacified loops of small and large bowel are unremarkable. Periumbilical diastasis of the rectus musculature is noted. There is no free intra-abdominal gas or fluid. CT OF THE PELVIS WITH IV CONTRAST: An open wound is noted from the patient's recent low transverse cesarean section. A small amount of fluid is present along the lower uterine segment caesarean section defect. There are three small distinct pockets of this fluid along the lower uterine segment defect, which along the right aspect measures less than 2 x 2 x 1 cm, and at the midline measures about 1 cm, and along the left aspect measures about 5 mm. There is no gas associated with the fluid. There is expected post- surgical inflammatory stranding between the rectus sheath and the uterus and also of the subcutaneous tissues near the incision. The uterus is enlarged consistent with post-partum state. There is a small amount of fluid and a tiny locule of gas within the vaginal cuff. The adnexa are unremarkable. There is no significant free pelvic fluid. Bladder and pelvic loops of bowel are unremarkable. BONE WINDOWS: No concerning lytic or sclerotic osseous lesions are seen. IMPRESSION: 1. Open wound from the patient's recent low transverse cesarean section with expected post-surgical change of the subcutaneous tissues. 2. Small lobulated fluid components along the lower uterine segment caesarean section defect ae likely evolving small hematomas, expected postoperative change. No associated gas to suggest infection, although this cannot be definitively excluded. . CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST (___) (preliminary report): CT OF THE ABDOMEN: Limited images through the lung bases are unremarkable. The liver is normal in size and contour. There is no intrahepatic or extrahepatic biliary dilatation. The gallbladder is collapsed. Incidental note is made of common origin of the middle and left hepatic veins. The pancreas, spleen, and adrenals are within normal limits. The kidneys enhance symmetrically. There is no hydronephrosis. There is no ascites. No pathologically enlarged intra-abdominal lymph nodes are identified. Small and large bowel are normal in caliber. There is a very small fat- containing umbilical hernia with an opening of approximately 9 mm. CT OF THE PELVIS: The urinary bladder is unremarkable. The uterus demonstrates heterogeneous enhancement compatible with recent postpartum state. There has been interval decrease in size of the uterus which now measures 8.2 cm in transverse x 5.3 cm in AP x 11.5 cm in craniocaudal ___ (previously 10.6 cm in transverse x 6.6 cm in AP x 14 cm in craniocaudal ___. The previously noted several small fluid pockets around the uterus have completely resolved. No new fluid collections are identified. There is no evidence for a pelvic abscess. There is no significant free pelvic fluid. A linear density of low attenuation is evident in the anteroinferior aspect of the uterus compatible with a C-section scar. There is a soft tissue defect in the lower anterior abdominal wall compatible with an open wound. IMPRESSION: Interval resolution of several small fluid pockets in the pelvis. No new fluid collections are identified. Interval decrease in size of the uterus. <MEDICATIONS ON ADMISSION> Percocet, ibuprofen, colace, iron <DISCHARGE MEDICATIONS> 1. Amoxicillin-Pot Clavulanate 875-125 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 3 days. Disp: *6 Tablet(s)* Refills: *0* <DISCHARGE DISPOSITION> Home With Service Facility: ___ <DISCHARGE DIAGNOSIS> - infected postoperative wound seroma requiring incision and drainage as well as antibiotics - bacteremia status post IV antibiotics <DISCHARGE CONDITION> stable <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> see nursing sheets continue wet to dry dressing changes twice daily continue augmentin 875mg twice daily through ___
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In the emergency department, the incision was opened, explored and drained, expressing all of the purulent fluid. The skin incision was opened about 10cm from the left side. The fascia was intact and the base of the incision was debrided. Wet to dry dressing was placed. Gram stain of the purulent fluid was done and an aerobic culture was obtained; no anaerobic culture was sent. Two sets of blood cultures were drawn. The patient was started on IV Zosyn and was admitted to the postpartum floor so that the infant could room with the patient. An infectious disease consult was requested and obtained on hospital day #1. The consult expressed concerned for persistent focus of infection tracking from the operative site to the surface leading to her wound infection. *) Infectious Disease - IV Zosyn was continued on the postpartum floor. A CT scan of the abdomen and pelvis demonstrated small lobulated fluid components along the lower uterine segment caesarean section without gas to suggest infection, that were interpreted as likely evolving small hematomas. The gram stain of the incisional drainage sent from the emergency department demonstrated 3+ polymorphonuclear leukocytes and 4+ gram negative rods. Mixed bacterial types grew out in culture, and there was sparse growth of Prevotella species, beta lactamase positive, in anaerobic culture. No antipyretic medications were administered, and the patient remained afebrile throughout her hospitalization until hospital day #10 when she developed a maximum temperature of 100.8. Her white blood count was not elevated, she had no increasing tenderness, the wound was clean with healthy appearing granulation tissue and there were no focal signs of infection. A CT of the abdomen and pelvis on hospital day #11 demonstrated resolution of the small hematomas and no new fluid collections. Wet to dry dressing changes were done twice daily, and the wound appeared clean with no erythema or purulence throughout. A repeat wound culture on ___ showed only probable contamination from skin flora. The fever of 100.8 on hospital day #10 was likely attributable to a superficial phlebitis at a former IV site. All IV access was discontinued on the evening of hospital day #12 and the patient was transitioned from IV Zosyn to oral Augmentin. She was discharged home on hospital day #13 on oral Augmentin to complete a 14 day course. The patient and her husband will change the incision dressings at home with visiting nurse assistance. *) Diarrhea - The patient developed watery diarrhea on hospital day #2 and was thus put on contact precautions. Daily stool samples were sent over three days and were all negative after which contact precautions were lifted.
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11164150-DS-9
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Patient recorded as having No Known Allergies to Drugs <ATTENDING> ___. <CHIEF COMPLAINT> Labor, fever of 102 <MAJOR SURGICAL OR INVASIVE PROCEDURE> primary low transverse cesarean section <HISTORY OF PRESENT ILLNESS> ___ year old Gravida 1 Para 0 at 40 weeks 3 days gestational age presented after spontaneous rupture of membranes with painful contractions. Denied vaginal bleeding. Good fetal movement. Denied recent illness. No nausea/vomiting/diarrhea. No shortness of breath or chest pain. Patient reports feeling chills the morning of admission. Prenatal Care: ___ ___ by 16wk u/s A+/Ab-/RPRNR/RI/HBSAg-/GBS+ FFS-nl anatomy, posterior placenta, S=D @ 28wks, S<D by 2 wks @ 16 wks Abnormal quad with increased DS risk and trisomy 18 risk, declined amnio UTI, tx w/ amox Low lying placenta, 2.2 cm from os. Subchorionic hematoma @ ___ wks ___ EFW 2944g 40% Nl GLT <PAST MEDICAL HISTORY> MedHx: Denies SurgHx: Appendectomy age ___ <SOCIAL HISTORY> ___ <FAMILY HISTORY> Noncontributory <PHYSICAL EXAM> Admission physical exam: VS 102.1 128/87 HR 120s Feeling uncomfortable RRR CTAB Abd soft, gravid, NT, EFW 7# by ___ Ext NT SVE ___ Toco q2-3mins FHT 170/min var/no accels/occ early and variable decels <PERTINENT RESULTS> WBC 18.1 - 18.5, 3 bands UA sm nitrite, tr glucose, 40 ketones, tr leuks, few bact (4 epi) ___ normal fibrinogen 643 Blood culture: ___ - gram stain gram negative rods, preliminary culture gram negative rods ___ - no growth to date Urine culture: no growth x 2 Placental pathology: pending <MEDICATIONS ON ADMISSION> prenatal vitamins <DISCHARGE MEDICATIONS> 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed. Disp: *60 Capsule(s)* Refills: *2* 2. Oxycodone-Acetaminophen ___ mg Tablet Sig: One (1) Tablet PO Q4-6H () as needed. Disp: *30 Tablet(s)* Refills: *0* 3. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed. Disp: *50 Tablet(s)* Refills: *2* 4. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO twice a day. Disp: *60 Tablet(s)* Refills: *2* <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> s/p primary LTCS for NRFHT, inadequate pelvis chorioamnionitis s/p antibiotics blood loss anemia, hct 25.6 <DISCHARGE CONDITION> stable <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> see nursing sheets take prenatal vitamin once a day take iron supplementation 2 times a day as tolerated
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The patient was admitted in labor, with fever and presumed chorioamnionitis. She was started on ampicillin and gentamicin. She made rapid change to full dilation, but was felt to have an inadequate pelvis in the setting of a nonreassuring fetal heart tracing. She underwent uncomplicated cesarean section. Please see full operative note for details. After the procedure, she was kept on labor and delivery for closer observation given fever, tachycardia, and hypotension and concern for sepsis. Clindamycin was added to her antibiotic regimen. Her fever curve began to trend down and vital signs began to normalize. She initially had low urine output, which responded to fluid bolus. Preliminary blood culture returned with gram negative rods. Repeat cultures x 2 are still pending on discharge. Urine cultures did not grow anything. She respiked to temperature of 100.8 on post-operative day #3. She was continued on ampcillin, gentamicin and clindamycin until 48 hours afebrile and antibiotics were discontinued early on post-operative day #5. She was discharged home late on post-operative day #5 with stable vital signs, still afebrile and with no further evidence of infection. She can follow up the final blood culture results as an outpatient.
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11166070-DS-12
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Keflex <ATTENDING> ___ <CHIEF COMPLAINT> uterine fiboids <MAJOR SURGICAL OR INVASIVE PROCEDURE> diagnostic laparoscopy, total abdominal hysterectomy <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> lorazepam with flying, h/o tramadol use <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 100 mg 1 capsule(s) by mouth twice daily Disp #*60 Capsule Refills: *0 3. Ibuprofen 600 mg PO Q6H: PRN Pain - Moderate take with food or milk RX *ibuprofen 600 mg 1 tablet(s) by mouth every 6 hours Disp #*50 Tablet Refills: *1 4. OxyCODONE (Immediate Release) 5 mg PO Q4H: PRN Pain - Moderate do not drink alcohol or drive RX *oxycodone 5 mg ___ tablet(s) by mouth every 4 hours Disp #*25 Tablet Refills: *0 <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> symptomatic fibroid uterus <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Dear Ms. ___, You were admitted to the gynecology service after your procedure. You have recovered well and the team believes you are ready to be discharged home. Please call Dr. ___ office with any questions or concerns. Please follow the instructions below. General instructions: * Take your medications as prescribed. * Do not drive while taking narcotics. * Take a stool softener such as colace while taking narcotics to prevent constipation. * Do not combine narcotic and sedative medications or alcohol. * Do not take more than 4000mg acetaminophen (APAP) in 24 hrs. * No strenuous activity until your post-op appointment. * Nothing in the vagina (no tampons, no douching, no sex) for 6 weeks. * No heavy lifting of objects >10 lbs for 6 weeks. * You may eat a regular diet. * You may walk up and down stairs. Incision care: * You may shower and allow soapy water to run over incision; no scrubbing of incision. No tub baths for 6 weeks. * If you have steri-strips, leave them on. They will fall off on their own or be removed during your followup visit. * If you have staples, they will be removed at your follow-up visit. Call your doctor for: * fever > 100.4F * severe abdominal pain * difficulty urinating * vaginal bleeding requiring >1 pad/hr * abnormal vaginal discharge * redness or drainage from incision * nausea/vomiting where you are unable to keep down fluids/food or your medication To reach medical records to get the records from this hospitalization sent to your doctor at home, call ___.
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On ___, Ms. ___ was admitted to the gynecology service after undergoing diagnostic laparoscopy, total abdominal hysterectomy. Please see the operative report for full details. Her post-operative course was uncomplicated. Immediately post-op, her pain was controlled with IV dilaudid, toradol. On post-operative day 1, her urine output was adequate so her foley was removed and she voided spontaneously. Her diet was advanced without difficulty and she was transitioned to oral ibuprofen, acetaminophen, oxycodone (pain meds). By post-operative day 2, she was tolerating a regular diet, voiding spontaneously, ambulating independently, and pain was controlled with oral medications. She was then discharged home in stable condition with outpatient follow-up scheduled.
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11166392-DS-10
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Allergies/ADRs on File <ATTENDING> ___. <CHIEF COMPLAINT> LLQ abdominal pain, s/p IVF with +HCG <MAJOR SURGICAL OR INVASIVE PROCEDURE> laparoscopic partial left salpingectomy cystoscopy <HISTORY OF PRESENT ILLNESS> ___ yo G1 at approximately 7 weeks GA who was sent to the ED from ___ IVF. Earlier today she was seen at ___ for LLQ pain and dizziness and there was concern for an ectopic pregnancy so she was sent to ___ for further evaluation. The patient reports that the pain started yesterday. She describes the pain as constantly crampy and ___ with occasional sharp pains which are more painful, ___. Her pain has been increasing since yesterday. She denies any other associated symptoms like nausea, vomiting, fever, chills, dysuria, diarrhea, headache. She is not currently dizzy anymore. She does report some constipation. She denies any history of prior ectopic pregnancy. <PAST MEDICAL HISTORY> OBH: G1. History of infertility seen at ___ IVF, s/p one cycle of IVF. GYNH: Denies any history of abnormal pap smears or STIs. She has a history of paratubal cysts and has had an open RSO as well as diagnostic laparoscopy. PMH: - ___'s thyroiditis - Protein S deficiency- on aspirin for it, last took it 2 days ago PSURGH: - open appendectomy for ruptured appendix - Dx laparoscopy x2 - open right salpingo-oophorectomy - shoulder surgery x3 <SOCIAL HISTORY> ___ <FAMILY HISTORY> Family history of BRCA gene mutation but has not been tested yet. Is planning to be tested in the future. <PHYSICAL EXAM> on admission: T-98.7 HR-76 BP-119/66 RR- 18 O2-100% Gen: NAD, uncomfortable Skin: warm and dry HEENT: NCAT, EOMI CV: RRR, no murmurs appreciated Pulm: CTAB, good air movement Abd: +BS, soft, tender in the RLQ on palpation, voluntary guarding, no rebound, non-distended Ext: Non-tender, no edema Pelvic: Normal appearing external genitalia, speculum exam revealed normal appearing cervix without lesions, no blood in the vaginal vault. Bimanual exam revealed a mobile uterus with exquisite tenderness on palpation to the left lower quadrant. + CMT. <PERTINENT RESULTS> ___ 12: 00PM BLOOD WBC-6.9 RBC-4.90 Hgb-13.5 Hct-39.1 MCV-80* MCH-27.6 MCHC-34.6 RDW-13.6 Plt ___ ___ 12: 00PM BLOOD Glucose-76 UreaN-8 Creat-0.7 Na-140 K-3.9 Cl-103 HCO3-26 AnGap-15 ___ 12: 00PM BLOOD HCG-752 <MEDICATIONS ON ADMISSION> Synthroid ___ mcg daily, aspirin 81 mg daily, PNV, fish oil, folic acid <DISCHARGE MEDICATIONS> 1. Percocet ___ mg Tablet Sig: ___ Tablets PO every ___ hours as needed for pain. Disp: *20 Tablet(s)* Refills: *0* 2. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day: take while on narcotic pain medication (percocet) to prevent constipation. Disp: *60 Capsule(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: *0* <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> left ectopic pregnancy <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> You were admitted for observation after undergoing a laparoscopic partial left salpingectomy and cystoscopy for left ectopic pregnancy. General instructions: * Take your medications as prescribed. * Do not drive while taking narcotics. * Do not combine narcotic and sedative medications or alcohol * Do not take more than 4000mg acetaminophen (APAP) in 24 hrs * No strenuous activity until your post-op appointment * No heavy lifting of objects >10lbs for 6 weeks. * You may eat a regular diet. Call your doctor for: * fever > 100.4 * severe abdominal pain * difficulty urinating * vaginal bleeding requiring >1 pad/hr * abnormal vaginal discharge * redness or drainage from incision * nausea/vomiting where you are unable to keep down fluids/food or your medication Incision care: * You may shower and allow soapy water to run over incision; no scrubbing of incision. No bath tubs for 6 weeks. * If you have 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 the evening of ___, Ms. ___ was admitted after undergoing laparoscopic partial left salpingectomy and cystoscopy for ectopic pregnancy. Please refer to operative report for details of the procedure. Her post-operative course was unremarkable. Because the preexisting pelvic adhesive disease made it difficult to perform a complete left salpingectomy and there was still concern of a possible ectopic pregnancy present, the need for methotrexate treatment as well as the risks, side effects, and follow up was discussed with the patient. She expressed understanding and consented to this therapy. She was given methotrexate IM prior to discharge. By POD#0, she was tolerating a regular diet, voiding spontaneously, ambulating independently, and pain was controlled by oral medications. She was then discharged home in good condition.
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11166392-DS-11
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> admission for preeclampsia <MAJOR SURGICAL OR INVASIVE PROCEDURE> spontaneous vaginal delivery <HISTORY OF PRESENT ILLNESS> Ms. ___ is a ___ G2P0 at 30+6 who presents for admission after ruling in for mild PEC. Patient had a booking BP of 120/70 but started to have elevated BP's 140s/90s at 30 weeks. She had a 24 hr urine protein on ___, which was positive at 330mg. She has been having headaches and using tylenol with improvement. She last used tylenol at 1600 this afternoon. She still complains of a mild headache rated ___. She denies any visual blurriness, or RUQ pain. She continues to have right sided pain. She denies any vaginal bleeding, leakage of fluid or painful contractions. She reports GFM. <PAST MEDICAL HISTORY> PNC: 1. ___ of ___ by LMP 2. Labs: A+/Ab-/RPRNR/RI/HepBSAg-/HIV-/GBS unk 3. Low risk ERA, normal FFS 4. US, FSS (placenta) 5. Normal GLT 6. Issues during pregnancy: IVF pregnancy. On lovenox 40mg SC daily for MTHFR heterezygote. Previously on prednisone and neupogen per Dr. ___. Booking BP 120/70. Recently with elevations in BP. POBHx: 1. 1 heterotopic s/p LSC salpingectomy and subsequent miscarriage of IUP. 2. G2 -> Current PGynHx: 1. Endometriosis with pelvic adhesive disease 2. Infertility PMHx: - MTHFR heterozygote - Hypothyroidism PSHx: - LSC salpingectomy, LSC CCY and LSC appe - Opec cystectomies and removal to fallopian tubes <SOCIAL HISTORY> ___ <FAMILY HISTORY> non-contributory <PHYSICAL EXAM> (on admission) Vitals: 98.1 73 18 140/96 -> 142/97 -> 130/91 No acute distress RRR no m/r/g CTAB ABD S/NT/Gravid 2+ b/l UE and ___ reflexes SVE: Deferred FHT: 130/mod var/+accels/no decels Toco: Flat TAUS: BPP ___, Cephalic presentation, AFI 15.6, Posterior placenta <PERTINENT RESULTS> ___ WBC-11.0 RBC-4.25 Hgb-12.3 Hct-35.5 MCV-84 Plt-211 ___ WBC-11.3 RBC-3.99 Hgb-11.9 Hct-33.1 MCV-83 Plt-204 ___ WBC-12.1 RBC-4.10 Hgb-11.9 Hct-34.4 MCV-84 Plt-149 ___ WBC-11.0 RBC-4.18 Hgb-12.3 Hct-35.8 MCV-86 Plt-145 ___ WBC-9.7 RBC-4.24 Hgb-12.5 Hct-36.5 MCV-86 Plt-135 ___ WBC-10.0 RBC-4.47 Hgb-12.7 Hct-37.9 MCV-85 Plt-133 ___ WBC-11.8 RBC-2.97 Hgb-8.7 Hct-25.7 MCV-87 Plt-220 ___ ___ PTT-30.6 ___ ___ ___ PTT-30.2 ___ ___ ___ PTT-30.1 ___ ___ ___ PTT-32.1 ___ ___ Creat-0.8 ALT-20 UricAcd-7.6 ___ Creat-0.8 ALT-19 UricAcd-8.5 ___ Creat-0.8 ALT-17 UricAcd-8.7 ___ Creat-0.8 ALT-15 UricAcd-9.8 ___ Creat-0.8 ALT-50 AST-61 UricAcd-10.3 Hapto-67 ___ Creat-0.8 ALT-61 AST-81 LD-329 UricAcd-10.1 ___ Creat-0.7 ALT-57 AST-74 UricAcd-9.7 ___ Creat-0.6 ALT-44 AST-44 UricAcd-8.2 Hapto-175 ___ URINE Blood-NEG Nitrite-NEG Protein-100 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG ___ URINE RBC-0 WBC-5 Bacteri-FEW Yeast-NONE Epi-45 TransE-2 ___ Hours-RANDOM Creat-22 TotProt-72 Prot/Cr-3.3 R/O GROUP B BETA STREP (Final ___: NEGATIVE FOR GROUP B BETA STREP. URINE CULTURE (Final ___: MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION. <MEDICATIONS ON ADMISSION> Vitamin D Folic Acid Lovenox 40mg SC daily Synthroid ___ daily <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> preterm delivery severe pre-eclampsia <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> see instruction sheet
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___ y/o G2P0 admitted at 30w6d with mild preeclampsia. Her blood pressures were 130-140s/90s on arrival. She reported intermittent headaches which improved with tylenol. Preeclampsia labs were notable for an elevated uric acid (7.6) and slightly elevated creatinine (0.8). Fetal testing was reassuring. She was admitted to the antepartum service for expectant management. She underwent close maternal and fetal surveillance. She received a course of betamethasone for fetal lung maturity and the NICU was consulted. There was appropriate fetal growth with an estimated fetal weight of 1631 grams, which is in the ___ percentile. She continued to report intermittent headaches. At 31w5d, she was started on po Labetolol given persistently elevated blood pressures. She remained clinically stable until 32w0d when she developed RUQ pain, rising LFTs, and a persistent headache. The decision was made to proceed with delivery given concern for severe preeclampsia. She underwent induction of labor and had a spontaneous vaginal delivery on ___ (32w1d) of a liveborn male weighing 1550g and apgars of 8 and 8. Her delivery was complicated by a postpartum hemorrhage (total EBL 750cc) which was managed with Picotin and Cytotec. . Ms ___ was treated with Magnesium sulfate intrapartum and for 24 hours postpartum. Her blood pressures initially were stable, then became persistently elevated to 150s/100 on PPD#3. She was discharged home on po Nifedipine 30mg CR on PPD#4.
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11166392-DS-12
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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> none <HISTORY OF PRESENT ILLNESS> ___ yo G3P1 @ ___ with IVF di/di twins presents with regular contractions for 6 hours. No fever or pain with urination. No vaginal bleeding or abdominal pain, no trauma, + active fetal movement. No LOF. <PAST MEDICAL HISTORY> PNC: - ___: ___ by IVF dating - A+/Ab-/RPRNR/RI/HBsAg-/HIV-/GC-/CT-/HepC- - LR ERA - FFS: normal x2 - Issues: *) Protein S def and antiphospholipid antibody syndrome, on lovenox *) h/o SPEC in prior pregnancy, on baby ASA. 24h protein on ___ mg. *) Short cervix: CL 1.6cm ___. BMZ complete ___ vaginal progesterone -> 2.5cm on ___ -> 1.4 on ___ OB Hx: G3P1 - SVD x 1 at 32wga after IOL for severe pre-eclampsia, - Ectopic/SAB x 1 (heterotopic pregnancy) GYN Hx: last pap ___ normal, history of salpingectomy for ectopic/heterotopic pregnancy, also salpingectomy of other tube due to adhesions PMH: - ___'s thyroiditis -> hypothyroidism - Rheumatoid arthritis PSH: - open appendectomy - left salpingectomy for ectopic - LSC-CCY - 3x rt shoulder surgery - laparotomy via ___, LOA, right salpingectomy, ovarian cystectomy <SOCIAL HISTORY> ___ <FAMILY HISTORY> non-contributory <PHYSICAL EXAM> (on admission) VITALS: T 98.0, BP 118/70, HR 81, RR 16 GENERAL: NAD, AxO ABDOMEN: Soft, NT, gravid EXTREMITIES: nontender, non edematous SVE: ___/ mid consistency/ posterior-> no change after 4 hours FHT: A 140/mod var/+accels/-decels, rNST B 140/mod var/+accels/-decels, rNST TOCO: periods of q5min-> periods of irritability <PERTINENT RESULTS> ___ WBC-9.4 RBC-4.28 Hgb-11.8 Hct-35.1 MCV-82 Plt-243 ___ Glu-73 BUN-5 Cre-0.5 Na-137 K-3.9 Cl-102 HCO3-25 AnGap-14 ___ Calcium-8.9 Phos-3.5 Mg-1.8 ___ URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG ___ URINE Color-Straw Appear-Clear Sp ___ ___ OTHER BODY FLUID FetalFN-NEGATIVE URINE CULTURE (Final ___: GRAM POSITIVE BACTERIA. >100,000 ORGANISMS/ML. R/O GROUP B BETA STREP (Final ___: NEGATIVE FOR GROUP B BETA STREP <MEDICATIONS ON ADMISSION> baby asprin lovenex ___ SC bid synthroid PNV iron Vit D vaginal progesterone Levoxyl 225 mcg <DISCHARGE MEDICATIONS> 1. Aspirin 81 mg PO DAILY 2. Heparin 10,000 UNIT SC BID RX *heparin (porcine) 10,000 unit/mL ___ units SC twice a day Disp #*60 Vial Refills: *2 3. Levothyroxine Sodium 200 mcg PO DAILY 4. Prenatal Vitamins 1 TAB PO DAILY 5. proGESTerone micronized 200 mg vaginal qhs 6. Syringe 3cc/25Gx1 (syringe with needle (disp)) 3 mL 25 x 1 miscellaneous BID heparin injection RX *syringe with needle (disp) 25 gauge X 1" use for heparin injections twice a day Disp #*60 Syringe Refills: *2 <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> pre-term contractions <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> You were admitted to the hospital for preterm contractions. You were given indomethacin to slow contractions and betamethasone, a steroid which helps the baby's lungs among other benefits. Your contractions and cervical exam remained stable and you are now safe to be discharged home. You should continue to use the vaginal progesterone. Your anticoagulation medication was changed from Lovenox to Heparin. You will be continued on Heparin for the remainder of your pregnancy. You should also continue to take the daily baby aspirin. Please call the office for: - Worsening/painful contractions - Vaginal bleeding - Leakage of water or concern that your water broke - Abdominal pain - Nausea/vomiting - Fever, chills - Decreased fetal movement
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___ G3P1 with di di twins admitted at 29w3d with preterm contractions and concern for preterm labor. On arrival, she was contracting irregularly and her cervix was 2cm/50%. She was started on Indomethacin for tocolysis and given a rescue course of betamethasone. She underwent prolonged monitoring on labor and delivery. Her cervical exam was unchanged four hours later and her contractions decreased significantly, therefore, she was transferred to the antepartum floor for further management. ___ was consulted and followed her. Given the concern for preterm labor, it was recommended that she switch from Lovenox to sc heparin. Fetal testing was reassuring. She was rescue ___ complete on ___. The Indomethacin was discontinued and she was closely observed. She continued to feel cramping and irregular contractions, however, made no further cervical change. She was discharged home on ___ in stable condition. Per ___ recommendations, she will continue taking heparin likely for the remainder of the pregnancy. She will have close outpatient followup.
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11167124-DS-14
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Augmentin <ATTENDING> ___. <CHIEF COMPLAINT> PIH eval <MAJOR SURGICAL OR INVASIVE PROCEDURE> vaginal delivery <HISTORY OF PRESENT ILLNESS> ___ G1 at 38+1 presented to triage for PIH eval after pressure 140/90 today for the first time. <PAST MEDICAL HISTORY> PNC: -___: ___ by ___ -Labs: A+/Ab-/HBsAg-/RPRNR/RI/HIV- /GBS- -Screening: LR NIPT -FFS: WNL, anterior placenta -GLT: 115, passed -Issues *AMA *extreme anxiety and difficulty with pelvic exams OBHx: G1 current GynHx: denies PMH: insomnia, anxiety PSH: WT Meds: PNV NKDA <SOCIAL HISTORY> no t/e/d <PHYSICAL EXAM> Physical exam on admission: -Gen: Anxious -Abd: gravid, soft, NT -Ext: soft, NT, mild edema -NST: 130, mod var, +accels, no decels -Toco: ctx q1-4min, pt completely unaware -TAUS: VTX at Dr. ___ PTA -___: 6.5-7# by Leoplods -SVE: L/C/P at Dr. ___ PTA ___ exam on discharge: General: NAD, A&Ox3 Breasts: non-tender, no erythema, soft, nipples intact Lungs: No respiratory distress Abd: soft, nontender, fundus firm at 2 cm below umbilicus, erythema well within marked borders, significantly improved from prior exam. no discharge, induration or fluctuance appreciated at incision Lochia minimal Extremities: no calf tenderness, no edema <PERTINENT RESULTS> ___ 04: 50PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 LEUK-NEG ___ 04: 50PM URINE COLOR-Straw APPEAR-Clear SP ___ ___ 04: 50PM PLT COUNT-253 ___ 04: 50PM WBC-13.6* RBC-4.45 HGB-13.7 HCT-39.6 MCV-89# MCH-30.8 MCHC-34.6 RDW-12.7 RDWSD-41.1 ___ 04: 50PM URIC ACID-7.6* ___ 04: 50PM ALT(SGPT)-33 AST(SGOT)-27 ___ 10: 59PM CREAT-0.7 ___ 10: 59PM ALT(SGPT)-37 AST(SGOT)-30 ___ 10: 59PM URIC ACID-7.8* ___ 10: 59PM WBC-18.2* RBC-4.36 HGB-13.4 HCT-39.1 MCV-90 MCH-30.7 MCHC-34.3 RDW-12.8 RDWSD-41.9 <MEDICATIONS ON ADMISSION> pnv <DISCHARGE MEDICATIONS> 1. Amoxicillin-Clavulanic Acid ___ mg PO Q12H would cellulitis/? pneumonia Duration: 6 Days RX *amoxicillin-pot clavulanate 875 mg-125 mg 1 (One) by mouth twice a day Disp #*14 Tablet Refills: *0 2. Ibuprofen 600 mg PO Q6H: PRN Pain - Moderate RX *ibuprofen 600 mg 1 tablet(s) by mouth four times a day Disp #*30 Tablet Refills: *0 3. NIFEdipine (Extended Release) 30 mg PO BID RX *nifedipine 30 mg 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills: *2 4. OxyCODONE (Immediate Release) ___ mg PO Q4H: PRN Pain - Severe RX *oxycodone 5 mg ___ tablet(s) by mouth four times a day Disp #*40 Tablet Refills: *0 <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> Preeclampsia, chorioamionitis, possible pneumonia, wound cellulitis <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Follow up NEXT WEEK for a wound check and then in 6 weeks for a postpartum exam
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Ms. ___ was transfered to the postpartum floor after undergoing a c-section for arrest of labor. Intrapartum, she developed pre-eclampsia, severe by BPs and ___, requiring IV antihypertensives, and underwent 24 hours of PP magnesium at a rate of 0.5gm/hr given her ___. She also developed chorio and underwent 24 hours of unasyn and clinda. On PPD1, she developed fever, acute SOB, with desaturation to 88% on RA requiring 02. She underwent a CTA to r/o PE. The CTA was negative for PE, but did show bilateral pleural effusion, a a possible consolidation and PNA could not be ruled out. Patient continued to be SOB with desaturations when off oxygen. The decision was made to give IV lasix given her fluid overload status. Given the fever, her antibiotics were broaden to zosyn. By POD2, the patient was weaned off 02 with 97% 02 saturation on RA. She was continued on zosyn and remained afebrile. At that time, an abdominal erythema was noted and thought to be cellulitis. On POD3-4, patient remained afebrile, was ambulating with out SOB or desaturations, was tolerating a regular diet, and her cellulitis was improving. She endorsed diarrhea and a c-diff was obtained which was negative. On POD4 she was transitioned to PO augmentin. By postpartum day 5, she was tolerating a regular diet, ambulating independently, and pain was controlled with oral medications. She was afebrile with stable vital signs. She was then discharged home in stable condition with postpartum outpatient follow-up scheduled.
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11167124-DS-15
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Augmentin <ATTENDING> ___. <CHIEF COMPLAINT> c-section <MAJOR SURGICAL OR INVASIVE PROCEDURE> c. section <HISTORY OF PRESENT ILLNESS> ___ was sent to triage after her last visit on ___ for elevated BPs in the office. She ruled in for gestational HTN and ruled out for preeclampsia. ___ has a h/o severe preeclampsia and acute kidney injury during her last pregnancy. Her baseline PIH labs this pregnancy were normal. On her triage visit they were also normal. A 24 hour urine showed protein less than 4 mg; UPC 0.2; All other labs normal except a uric acid of 6. 6. She has been on ASA 81 until 36 weeks. She was discharged home to have c/s moved up from ___ to today though that was never set up apparently since she showed up for today's visit. Today her Bp 156/98; repeat 140/90; protein negative; Denies h/a, visual change or epigastric pain; Reports very AFM. <PAST MEDICAL HISTORY> PNC: -___: ___ by LMP -Labs: A+/Ab-/HBsAg-/RPRNR/RI/HIV- /GBS- -Screening: LR NIPT -FFS: WNL, anterior placenta -GLT: 115, passed -Issues *AMA *extreme anxiety and difficulty with pelvic exams OBHx: G1 current GynHx: denies PMH: insomnia, anxiety PSH: WT Meds: PNV NKDA <SOCIAL HISTORY> no t/e/d <PHYSICAL EXAM> Physical exam on day of discharge General: NAD CV: RRR Lungs: Nonlabored breathing, CTAB Abd: soft, fundus firm at umbilicus, appropriate fundal tenderness Incision: dressing C/D/I, no erythema/induration Lochia: minimal Extremities: no calf tenderness, no edema Neuro: reflexes symmetric b/l, no clonus <PERTINENT RESULTS> ___ 02: 20PM CREAT-0.7 ___ 02: 20PM ALT(SGPT)-18 AST(SGOT)-21 ___ 02: 20PM URIC ACID-6.3* ___ 02: 20PM URINE HOURS-RANDOM CREAT-120 TOT PROT-18 PROT/CREA-0.2 ___ 02: 20PM WBC-15.5* RBC-3.98 HGB-12.2 HCT-37.4 MCV-94 MCH-30.7 MCHC-32.6 RDW-12.9 RDWSD-44.1 ___ 02: 20PM NEUTS-78.0* LYMPHS-14.5* MONOS-5.0 EOS-0.8* BASOS-0.5 IM ___ AbsNeut-12.11* AbsLymp-2.25 AbsMono-0.77 AbsEos-0.12 AbsBaso-0.07 ___ 02: 20PM PLT COUNT-218 ___ 02: 20PM URINE COLOR-Yellow APPEAR-Clear SP ___ ___ 02: 20PM URINE BLOOD-MOD* NITRITE-NEG PROTEIN-TR* GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-SM* ___ 02: 20PM URINE RBC->182* WBC-17* BACTERIA-NONE YEAST-NONE EPI-0 ___ 02: 20PM URINE MUCOUS-RARE* ___ 08: 54AM WBC-11.4* RBC-4.28 HGB-12.8 HCT-39.7 MCV-93 MCH-29.9 MCHC-32.2 RDW-12.8 RDWSD-43.4 ___ 08: 54AM PLT COUNT-236 <MEDICATIONS ON ADMISSION> prenatal <DISCHARGE MEDICATIONS> 1. Ibuprofen 600 mg PO Q6H: PRN Pain - Moderate RX *ibuprofen 600 mg 1 tablet(s) by mouth four times a day Disp #*30 Tablet Refills: *1 2. Labetalol 600 mg PO BID RX *labetalol 300 mg 2 tablet(s) by mouth twice a day Disp #*120 Tablet Refills: *0 3. NIFEdipine (Extended Release) 30 mg PO DAILY RX *nifedipine 30 mg 1 tablet(s) by mouth once a day Disp #*30 Tablet Refills: *0 4. OxyCODONE (Immediate Release) ___ mg PO Q4H: PRN Pain - Severe RX *oxycodone 5 mg 1 tablet(s) by mouth four times a day Disp #*20 Tablet Refills: *0 <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> c. section gestational hypertension, severe <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Followup 6 weeks for postpartum check blood pressure check in 2 days ___ in office home blood pressure measurement 4 times daily
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Ms. ___ presented for an elective Caesarean delivery to the Labor and Delivery floor. She underwent a repeat low transverse Caesarean section on ___. Her postpartum course was complicated by pre-eclampsia with severe features by blood pressures. She completed a 24 hour course of magnesium infusion on ___. She had severe range blood pressures on ___ and received IV hydral. Her serum PIH labs obtained were within normal limit. She continued to have elevated blood pressures and her anti-hypertensive medications were uptitrated to labetolol 600mg BID and nifedipine 30mg daily. Her pain was treated with oral pain medications. She ambulated and her foley was discontinued and she voided spontaneously. Her diet was advanced without incident. By postpartum day ___, she was tolerating a regular diet, ambulating independently, and pain was controlled with oral medications. She was afebrile with stable vital signs. She was then discharged home in stable condition with postpartum outpatient follow-up scheduled.
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11168666-DS-12
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Tetracycline / Apple / Strawberry / Coconut Flavor <ATTENDING> ___ <CHIEF COMPLAINT> Uterine fibroids <MAJOR SURGICAL OR INVASIVE PROCEDURE> total laparoscopic hysterectomy, cystoscopy <HISTORY OF PRESENT ILLNESS> This is a ___ gravida 3, para 0, TAB x 3 with a long history of pelvic pain and uterine fibroids. The patient has had multiple GYN procedures including a termination of pregnancy x3, multiple myomectomy, bilateral ovarian cysts drainage ___ with Dr. ___, left uterosacral biopsy, which showed benign fibroadipose tissue with small mesothelial simple cyst and lysis of adhesions. The patient reports that her pelvic pain continues. She states that it is daily and certainly worsens with menses or ___ to ___. She has undergone multiple medical treatments including oral contraceptive pills, NuvaRing patch, she was treated with Lupron in ___ and Mirena IUD. In ___, she received Lupron 11.25 mg. She also tends to relieve her pain with Tylenol No. 3. The patient is adamant about no future pregnancy. She comes today to discuss definitive management of her chronic pelvic pain in the form of a total hysterectomy. She does desire preservation of her ovaries. She has no documented history of endometriosis. <PAST MEDICAL HISTORY> OB/GYN HISTORY: Menarche at age ___. She cycles monthly every 28 days. Her bleeding usually lasts for ___ days. She has no history of abnormal Pap smears. Last Pap was within the year and it was negative for dysplasia or malignancy. She has no history of sexually transmitted infections. She is sexually active, prefers men. Again, she has had three pregnancies, all resulted in termination without complications. PAST MEDICAL HISTORY: bilateral osteoarthritis of her knees, varicose veins. SURGICAL HISTORY: TAB x 3, myomectomy in ___ with bilateral ovarian cysts drainage in ___, a laparoscopic left uterosacral biopsy and lysis of adhesions. <SOCIAL HISTORY> ___ <FAMILY HISTORY> Hypertension, cardiovascular disease, stroke, and fibroids. Negative history of female cancers <PHYSICAL EXAM> Physical Examination on Discharge: VSS CV RRR PULM CTAB ABD soft, nontender, incisions C/D/I, +BS EXT warm well perfused, nontender to palpation <MEDICATIONS ON ADMISSION> The Preadmission Medication list is accurate and complete. 1. Ibuprofen 600 mg PO Q6H: PRN pain <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. Oxycodone-Acetaminophen (5mg-325mg) ___ TAB PO Q4H: PRN pain RX *oxycodone-acetaminophen 5 mg-325 mg 1 tablet(s) by mouth Every 4 hours Disp #*30 Tablet Refills: *0 3. Ibuprofen 600 mg PO Q6H: PRN pain RX *ibuprofen 600 mg 1 tablet(s) by mouth Every 6 hours Disp #*60 Tablet Refills: *0 <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> pelvic pain, uterine fibroids <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Ms. ___, It was a pleasure caring for you at ___ ___. You were admitted to the gynecology service after your surgery. You did well post-operatively and were able to eat and drink, ambulate, void on your own and your pain was well controlled with pain pills that you can continue to take at 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 three months * No heavy lifting of objects >10lbs for 6 weeks. * You may eat a regular diet Incision care: * You may shower and allow soapy water to run over incision; no scrubbing of incision. No bath tubs for 6 weeks. Call your doctor for: * fever > 100.4 * severe abdominal pain * difficulty urinating * vaginal bleeding requiring >1 pad/hr * abnormal vaginal discharge * redness or drainage from incision * nausea/vomiting where you are unable to keep down fluids/food or your medication To reach medical records to get the records from this hospitalization sent to your doctor at home, call ___.
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Ms ___ underwent an uncomplicated total laparoscopic hysterectomy, cystoscopy ; see operative report for details. She had an uncomplicated recovery and was discharged home on postoperative day #2 in good condition: ambulating and urinating without difficulty, tolerating a regular diet, and with adequate pain control using PO medication. Patient has follow up scheduled with Dr. ___.
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11169538-DS-11
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> amlodipine / hydrochlorothiazide / enalapril / Statins-Hmg-Coa Reductase Inhibitors / ferrous sulfate / ezetimibe <ATTENDING> ___. <CHIEF COMPLAINT> endometrial cancer <MAJOR SURGICAL OR INVASIVE PROCEDURE> total laparoscopic hysterectomy, bilateral salpingo-oophorectomy <HISTORY OF PRESENT ILLNESS> Ms. ___ is a ___ who had postmenopausal bleeding. As part of her evaluation, she underwent a pelvic ultrasound at ___ on ___ which showed a uterus" 6.1 x 2.5 x 4.2 cm with heterogenous echotexture without exophytic left side of posterior fibroid 1 cm in size and the left sided exophytic heterogenous mass 1.8 cm. Her endometrium is 5 mm. The right ovary measures 1.9 cm, the left ovary measuring cystic with no definite ovarian tissue; however, there is a cystic lesion measuring 4.4 cm with an 8 mm wall nodule." She had a pelvic MRI on ___ which showed a mass in the left adnexa and ovoid T1 hypointensity, T2 hyperintense mass measuring up to 3.5 cm with no associated nodular enhancement or fixed septations. The right ovary does not appear enlarged. Uterine fibroids were again seen. She underwent an endometrial biopsy on ___ at ___ performed for postmenopausal bleeding with " superficial fragments of endometrium with complex echotexture and squamous metaplasia highly suspicious for a well differentiated endometrial adenocarcinoma." The pathology was reviewed at ___ and was found to be consistent with Grade 1 endometrial adenocarcinoma. She was seen in the ___ clinic and surgery was recommended and she agreed with the plan to proceed with total hysterectomy and bilateral salpingo-oophorectomy and possible lymph node dissection. postmenopausal bleeding and underwent an endometrial biopsy in early ___, which was reviewed and found to be a grade 1 endometrial adenocarcinoma. She was evaluated in the ___ and consented for surgery. All of her questions were answered to her apparent satisfaction. <PAST MEDICAL HISTORY> PMH: obesity, hypertension, atrial fibrillation, T2DM, hepatic hemangioma and cyst PSH: pulmonary vein ablation (___) OB/GYN: - G1P0 - postmenospausal, remote history of abnormal pap smears with normal follow-up, no history of HRT use <SOCIAL HISTORY> ___ <FAMILY HISTORY> There are no known cancers in the family. Her sister also has diabetes, her mother has high blood pressure, and her father and her mother both had heart disease. <PHYSICAL EXAM> On day of discharge: Afebrile, vitals stable No acute distress CV: regular rate and rhythm Pulm: clear to auscultation bilaterally Abd: soft, appropriately tender, nondistended, port site incisions clean/dry/intact with steristrips in place, no rebound/guarding ___: nontender, nonedematous <PERTINENT RESULTS> ___ 08: 02AM BLOOD WBC-11.4* RBC-4.20 Hgb-10.6* Hct-33.2* MCV-79* MCH-25.2* MCHC-31.9* RDW-14.6 RDWSD-42.0 Plt ___ ___ 08: 02AM BLOOD Neuts-79.6* Lymphs-13.6* Monos-6.0 Eos-0.1* Baso-0.2 Im ___ AbsNeut-9.04*# AbsLymp-1.55 AbsMono-0.68 AbsEos-0.01* AbsBaso-0.02 ___ 08: 02AM BLOOD Plt ___ ___ 12: 25PM BLOOD ___ PTT-36.2 ___ ___ 08: 02AM BLOOD Glucose-136* UreaN-12 Creat-0.8 Na-140 K-4.1 Cl-105 HCO3-26 AnGap-13 ___ 08: 02AM BLOOD Calcium-9.5 Phos-3.7 Mg-1.8 <MEDICATIONS ON ADMISSION> The Preadmission Medication list is accurate and complete. 1. irbesartan 75 mg oral daily 2. Metoprolol Succinate XL 25 mg PO DAILY 3. MetFORMIN XR (Glucophage XR) 1500 mg PO DAILY 4. Dofetilide 375 mcg PO Q12H 5. Rivaroxaban 20 mg PO DAILY 6. Omeprazole 20 mg PO DAILY 7. Vitamin D 1000 UNIT PO DAILY 8. Calcium Carbonate 500 mg PO DAILY PRN heartburn <DISCHARGE MEDICATIONS> 1. Dofetilide 375 mcg PO Q12H 2. irbesartan 75 mg oral daily 3. Metoprolol Succinate XL 25 mg PO DAILY 4. Omeprazole 20 mg PO DAILY 5. Acetaminophen ___ mg PO Q6H: PRN pain RX *acetaminophen 500 mg ___ tablet(s) by mouth every six (6) hours Disp #*50 Tablet Refills: *1 6. Calcium Carbonate 500 mg PO DAILY PRN heartburn 7. MetFORMIN XR (Glucophage XR) 1500 mg PO DAILY 8. Vitamin D 1000 UNIT PO DAILY 9. Ibuprofen 400 mg PO Q6H: PRN pain RX *ibuprofen 400 mg 1 tablet(s) by mouth every six (6) hours Disp #*50 Tablet Refills: *1 10. OxycoDONE (Immediate Release) ___ mg PO Q4H: PRN pain ___ cause drowsiness, do not drive while taking RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours Disp #*50 Tablet Refills: *0 11. Rivaroxaban 20 mg PO DAILY Restart on ___ as instructed 12. Docusate Sodium 100 mg PO BID RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day Disp #*60 Capsule Refills: *2 <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> endometrial cancer <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Dear Ms. ___ . You were admitted to the gynecologic oncology service after undergoing the procedures listed below. You have recovered well after your operation, and the team feels that you are safe to be discharged home. Please follow these instructions: . Laparoscopic instructions: * Take your medications as prescribed. * Do not drive while taking narcotics. * Do not combine narcotic and sedative medications or alcohol. * Do not take more than 4000mg acetaminophen (APAP) in 24 hrs. * No strenuous activity until your post-op appointment. * Nothing in the vagina (no tampons, no douching, no sex) for 12 weeks * No heavy lifting of objects >10 lbs for 4 weeks. * You may eat a regular diet. * It is safe to walk up stairs. . . Incision care: * You may shower and allow soapy water to run over incision; no scrubbing of incision. No bath tubs for 6 weeks. * You should remove your port site dressings ___ days after your surgery. If you have steri-strips, leave them on. If they are still on after ___ days from surgery, you may remove them. . Anti-coagulation instructions: Please restart your Xarelto on ___ and follow-up with your cardiologist as scheduled. . To reach medical records to get the records from this hospitalization sent to your doctor at home, call ___. .
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Ms. ___ was admitted to the gynecologic oncology service after undergoing a total laparoscopic hysterectomy and bilateral salping-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 pain medications. Her diet was advanced without difficulty and she was transitioned to oral pain medications with oxycodone, acetaminophen, and ibuprofen. On post-operative day #1, her urine output was adequate so her Foley catheter was removed and she voided spontaneously. For her history of atrial fibrillation, she was monitored on telemetry and remained in normal sinus rhythm. Her anti-arrhythmic medication was continued. Her Xarelto was held pre-operatively after discussion with her cardiologist with a plan to restart 72 hours post-operatively. For her hypertension, her beta blocker was continued throughout the perioperative period. For her history of type 2 DM, her fingersticks were monitored and her metformin was restarted when tolerating a regular diet. 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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11170197-DS-20
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___ ___ Complaint: SROM <MAJOR SURGICAL OR INVASIVE PROCEDURE> CS <HISTORY OF PRESENT ILLNESS> ___ G10P6 at 32w6d BIBA to ED for gush of fluid at ___, clear. Transferred to L+D. Here, still intermittent leaking. Feels AFM. Denies VB. Occasional contractions. Otherwise no F/C/N/V. Followed by Dr. ___ vaginal bleeding at 29 wga, ? chronic abruption. Got BMZ 1.5 weeks ago for continued small episodes of bleeding. Fetal testing has otherwise been reassuring. PNC: *) Dating: EDC: ___ by LMP *) Labs: A neg/Ab neg/RPRNR/RI/HbsAg neg/GBS + by UTI *) Routine: - per pt benign prenatal course, but full records unavailable. - no GLT *) Issues - ? Chronic abruption. Transferred care from ___ midwife practice to Dr. ___. Per pt testing has been reassuring. Was made BMZ complete. <PAST MEDICAL HISTORY> POBHx: SVD x6, multiple home births, largest 10+ lbs. Retained placenta requirine manual removal with birth #5, no placental problems with birth #6. SAB x 3. PGynHx: Denies STDs or abnl paps PMH: Benign PSH: LSC appendectomy ___ <SOCIAL HISTORY> ___ <FAMILY HISTORY> none <PHYSICAL EXAM> T 98.7 HR 93 RR 16 BP 124/58 NAD RRR CTAB Abd soft, gravid, NT SSE: Pooling in vagina. Cervix not visualized. Nitrazine positive. Ferns positive. SVE: ext os 2cm, internal os closed but very difficult to reach. cervix long. FHT: 155/mod var/+ accels/no decels Toco: Q4-7 Exam on discharge AVSS A&O NARD RRR CTAB abd soft, NT, FFBU, +BS min spotting on pad ext no calf TTP <PERTINENT RESULTS> ___ 10: 17AM BLOOD WBC-13.8*# RBC-3.58* Hgb-9.4*# Hct-28.3* MCV-79*# MCH-26.3*# MCHC-33.3 RDW-16.9* Plt ___ ___ 07: 00AM BLOOD Hct-26.7* ___ 10: 17AM BLOOD ___ PTT-22.1 ___ ___ 10: 17AM BLOOD ___ ___ 09: 46PM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-40 Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG ___ 9: 46 pm URINE Source: Catheter. **FINAL REPORT ___ URINE CULTURE (Final ___: NO GROWTH. <MEDICATIONS ON ADMISSION> PNV <DISCHARGE MEDICATIONS> 1. breast pump Sig: One (1) every four (4) hours: hospital grade baby in NICU . Disp: *1 1* Refills: *0* <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> PPROM abruption <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 ___ was admitted to labor and delivery following preterm rupture of membranes and was found to be in labor. A neonatology consult was obtained. On hospital day #1 Ms ___ underwent spontaneous vaginal delivery requiring manual removal of the placenta; see delivery note for full details. Her postpartum course was complicated by postpartum fevers. Following manual placental removal Ms ___ was begun on gentamicin and clindamycin for empiric treatment of endometritis. On postpartum day #1 her temperature was 101.9F and ampicillin was added. She remained afebrile after that and the ampicillin, gentamicin, and clindamycin were discontinued after more than 36 hours afebrile. Ms ___ was discharged home on postpartum day #3 in stable condition.
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11170197-DS-21
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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 ___ who presents to the ED with vaginal bleeding. Pt has a known placenta previa and lives just one block away from the hospital. She believes that she will be delivering at ___. She reports lying on her bed and feeling a big gush of fluid. She looked down and her pants were soaked with blood. She has not had any vaginal bleeding since. She reports some abdominal cramping at the time of her gush, but this has since subsided. She denies shortness of breath, chest pain or chest palpitations. She denies vtx, LOF and reports +FM ROS: Denies fevers/chills or recent illness. Denies HA, vision changes, RUQ/epigastric pain. Denies chest pain, shortness or breath, palpitations. Denies abd pain. Denies recent falls or abd trauma. Denies any unusual foods/undercooked foods, nausea, vomiting, diarrhea. <PAST MEDICAL HISTORY> PNC: (per patient, records pending) - ___ ___ - Labs Rh neg per patient (all other labs unknown) - Screening: LR (patient cannot remember which test) - FFS: complete previa, wnl - GTT: not yet completed - U/S: last ultrasound demonstrated a partial placenta previa - Issues #grand multiparity #placenta previa OBHx: - SVD x 8, largest 10# (one induction of labor at 42wks for oligo, one at 32wks in the setting of vaginal bleeding, PPROM and PTL; and one complicated by manual removal of placenta; all other SVD at 42wks) - ___ trimester MAB x ___ s/p D&C (14 and 16wks) - ___ trimester MAB x 4 (2 in OR and ___ MVA); pt reports most recent in ___ was c/b hemorrhage but did not require transfusion GYNHx: - Denies hx of abnormal pap, STIs or known fibroids or ovarian cysts PMH: benign brain tumor PSH: - D&E x 2 - D&C x 2 (+MVA x 2) - craniotomy ___ - ___ appendectomy ___ <SOCIAL HISTORY> ___ <FAMILY HISTORY> none <PHYSICAL EXAM> (on admission) Vitals: ___ 01: 08Temp.: 98.2°F ___ 01: 08BP: 125/57 (70) ___ ___: 93 Gen: A&O, comfortable Pulm: nl work of breathing Abd: soft, gravid, nontender to palpation, no CVAT bilaterally Ext: no calf tenderness SVE: deferred SSE: closed cervix, one scopet of blood in the vaginal vault, no active bleeding, normal physiologic discharge FHT 140/mod var/+accels/-decels Toco: flat, no ctx TAUS: breech, anterior placenta, BPP ___, MVP 3.73, EFW 1223g <PERTINENT RESULTS> ___ WBC-9.5 RBC-3.74 Hgb-10.7 Hct-32.9 MCV-88 Plt-124 ___ ___ PTT-24.3 ___ ___ URINE Blood-SM Nitrite-NEG Protein-TR Glucose-NEG Ketone-80 Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG ___ URINE RBC-2 WBC-<1 Bacteri-FEW Yeast-NONE Epi-3 ___ 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 STREP URINE CULTURE (Final ___: MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION <MEDICATIONS ON ADMISSION> none <DISCHARGE MEDICATIONS> none <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> 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> Dear Ms. ___ were admitted to the hospital for vaginal bleeding. You were given betamethasone, a steroid which helps the baby's lungs among other benefits. Your bleeding stopped and you are now safe to be discharged home.
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___ with a known placenta ___ was admitted on ___ with her first bleed. She received betamethasone course, and her course was completed on ___. She was observed as an inpatient. She did not have any evidence of contractions during her inpatient stay and she did not have any further evidence of bleeding during her stay. The patient declined Rh immune globulin as she states her husband is also RH negative. The patient also declined her TDAP vaccine and HIV routine screening. The patient was seen by anesthesia given a history of craniectomy. For fetal well being, the patient had reactive NSTs daily, and a BPP that was ___ on ___. She was seen by neonatology on ___. The patient was discharged on ___ without any vaginal bleeding since admission. She will follow-up with her primary OB as scheduled.
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11172646-DS-12
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Codeine / Heparin Agents / Adhesive Tape <ATTENDING> ___ <CHIEF COMPLAINT> pelvic pain, large pelvic cystic mass <MAJOR SURGICAL OR INVASIVE PROCEDURE> Exploratory laparotomy with lysis of adhesions; bilateral salpingo-oophorectomy; cystoscopy. <HISTORY OF PRESENT ILLNESS> This is a ___ gravida 2, para 2. The patient is status post total abdominal hysterectomy for symptomatic fibroids at age ___. This patient has a complicated medical history. She has a history of Behcet's syndrome and she is on chronic immunosuppression with prednisone. She has had multiple complaints, some related to this syndrome including multiple cysts that have needed to be excised on her extremities. She has complaints of back and leg pain, whole body pain. The patient has episodes of urinary frequency and was evaluated. That evaluation included an ultrasound. On ___, an ultrasound showed a large mass seen midline in the pelvis. This mass appeared to consist of two cysts that measured 7.9 x 4.7 x 5.0 cm and 5.6 x 4.6 x 4.7 cm, vascularity is seen between the two cysts and above the right lateral border of the cyst. Dense low flow echoes were seen within the cyst. The mass abuts both ovaries; however, could not be definitely connected to either ovary. The right ovary appeared normal with a small follicle. Left ovary contained a 1.7 cm simple cyst. There was no free fluid seen within the pelvis. The patient also had a CAT scan done prior to that ultrasound on ___. The findings revealed some left mid lung field scarring. The liver and spleen showed normal size and attenuation. The adrenal glands were not enlarged. The pancreas appeared normal. Both kidneys showed normal size and location, no renal masses or obstructive changes were seen. There was a probable 1 mm calculus in the lower pole of the left kidney. There was no adenopathy or ascites. The study was carried to the pelvis. There was an ostomy seen in the right lower abdomen. The urinary bladder appeared grossly normal. There was an oval structure in the pelvis measuring approximately 7.2 cm with intermediate to low density. There was no adenopathy or ascites. After intravenous administration of contrast was done, there was no enhancing lesions seen within the liver, spleen, pancreas, adrenal glands, or either kidney. There was no adenopathy or ascites revealed. Uterus was deemed normal in course and caliber to the urinary bladder. The abnormality in the pelvis did not significantly enhance. These findings were reviewed with the patient and her husband. The patient voiced frustration in the fact that she has been cared for at the ___ and ___, ___. She has seen three different gynecologists who arranged for her procedure; however, these surgeries were then canceled at the last moment. She states the reason for the cancellation of her surgery is that the general gynecologists felt that her case was "too complicated." Again, this patient has Behcet's syndrome which was thought to have led to a history of severe constipation. In ___, patient underwent an ileostomy in order to relieve the pain of defecation. The patient notes that since that procedure, she has had improvement in that area. The patient apparently had a severe neurologically induced disease that she was having bowel movements only once a month and that caused tremendous discomfort. She has no concerns around the functioning of her ileostomy. <PAST MEDICAL HISTORY> OB/GYN HISTORY: Menarche at age ___. Prior to her hysterectomy, she cycled monthly. Again she notes that she had increasing pressure and pain from fibroids and had a hysterectomy at age ___. She is sexually active at present with her husband. She has had two pregnancies in ___ and ___. Both being difficult secondary to having large babies and history of gestational diabetes. Her last Pap was normal. She denies any history of abnormal Pap smears and since she has had a total abdominal hysterectomy, there is no need for any further Paps. She denies any history of sexually transmitted infections. However, she has had genital ulcers related to Behcet's syndrome. PAST MEDICAL HISTORY: Significant for Behçet's syndrome, thrombophlebitis, migraine headaches, anemia, diabetes, hypertension, kidney stones, depression, joint disease, chronic pain syndrome, lumbar spondylosis, and lumbar degenerative disc disease. <SOCIAL HISTORY> ___ <FAMILY HISTORY> FAMILY HISTORY: Significant for uncle with stomach cancer, cousin with breast cancer who died at age ___ on the maternal side of the family. She has a brother with ___ disease, hypertension, and kidney disease in the family as well. She denies any history of uterine, cervical, colon, or ovarian cancer. <PHYSICAL EXAM> PHYSICAL EXAMINATION: GENERAL: This is a well-developed, well-nourished woman in no apparent distress. HEENT: Normocephalic, atraumatic. Sclerae anicteric, conjunctivae pink. Oropharynx clear. NECK: Supple, without increased thyroid, lymph system negative. ABDOMEN: Obese, soft, nondistended, nontender. There are no masses or organomegaly. She has tenderness in the lower quadrant. The ileostomy in the right lower quadrant appears to be functioning well. PELVIC: Normal female external genitalia. Bartholin, urethral, and Skene's glands normal. Vaginal vault, normal appearing discharge, no lesions. Cervix, uterus surgically absent. Adnexa impossible to evaluate, there is a fullness in the midline and posterior pelvis fullness consistent with 10-12 cm. The patient is tender when this area is palpated per vagina and per rectum. <MEDICATIONS ON ADMISSION> The patient's medication list includes Cymbalta 60 mg per day, Protonix 40 mg per day, Lomotil 10 mg in the a.m. and in the p.m., Zolpidem 10 mg at bedtime, Avinza 60 mg daily, Zofran 4 mg as needed, Percocet ___ as needed, Ativan 1 mg as needed, fish oil 4000 mg per day, vitamin D 1000 mg per day. <DISCHARGE MEDICATIONS> 1. Duloxetine 30 mg Capsule, Delayed Release(E.C.) Sig: Two (2) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 2. Morphine 30 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO Q12H (every 12 hours). 3. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) as needed for anxiety. 4. Lorazepam 1 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime) as needed for Anxiet/Insomnia. 5. Zolpidem 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime) as needed for insomnia. 6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 7. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Hydromorphone 4 mg Tablet Sig: ___ Tablets PO Q4H (every 4 hours) as needed for breakthrough pain. Disp: *60 Tablet(s)* Refills: *0* 9. Oxycodone 5 mg Tablet Sig: ___ Tablets PO Q4-6H () as needed for Pain. Disp: *60 Tablet(s)* Refills: *0* 10. Ibuprofen 400 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain. Disp: *60 Tablet(s)* Refills: *1* 11. Fluticasone-Salmeterol 100-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation BID (2 times a day). 12. Diphenoxylate-Atropine 2.5-0.025 mg Tablet Sig: ___ Tablets PO BID (2 times a day) as needed for high ostomy output. 13. Zofran 4 mg Tablet Sig: ___ Tablets PO every eight (8) hours as needed for nausea. Disp: *30 Tablet(s)* Refills: *0* <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> pelvic pain large cystic pelvic mass abdominal adhesions <DISCHARGE CONDITION> stable <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> please call your doctor's office if you have a fever, increasing pain despite your pain medications, nausea/vomiting where you are unable to tolerate any food or water, chest pain, shortness of breath, redness/drainage/swelling at your incision.
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Ms. ___ underwent an ___, LOA, BSO, cystoscopy for R adnexal mass. Please see separate operative note for intraoperative details. Overall, she did well post-op. Her diet was advanced as tolerated to regular, ___ was d/c'ed on post-op day #1, she ambulated without difficulty and pain was overall well-controlled. Due to chronic pain issues at baseline, the patient had an epidural placed prior to the procedure. The epidural was kept in until POD #1, at which time she was transitioned to her home regimen of oral pain medications: percocet, MS contin, ibuprofen and we also gave Dilaudid to better control the pain. An optimal pain regimen was achieved by Post-op day #3 and she was discharged home in stable condition on all of her home medications in addition to PO dilaudid. The acute pain service followed her while she was in house.
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11172646-DS-13
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Codeine / Heparin Agents / Adhesive Tape <ATTENDING> ___ <CHIEF COMPLAINT> Abdominal pain <MAJOR SURGICAL OR INVASIVE PROCEDURE> Trigger point injection into the scar neuroma <HISTORY OF PRESENT ILLNESS> Ms. ___ is a ___ yo G2P2 with a PMH significant for Behcet's Syndrome, recent ex lap, LOA and BSO on ___ for an adnexal mass and chronic pain issues who presents to Gyn Triage with a one day history of ___ LLQ pain. She describes the pain as constant, sharp and non-radiating. Of note, she also states that she feels a small "lump" beneath the skin in the area of the pain. Ms. ___ states that she feels this may be a neuroma given that she has had two neuromas after prior surgeries. She also notes some urinary hesitancy and decreased urine output over the past several days. She denies any fever, chills, intolerance to food, nausea/vomiting, change in her ostomy output, dysuria or vaginal bleeding. <PAST MEDICAL HISTORY> OB/GYN HISTORY: Menarche at age ___. Prior to her hysterectomy, she cycled monthly. Again she notes that she had increasing pressure and pain from fibroids and had a hysterectomy at age ___. She is sexually active at present with her husband. She has had two pregnancies in ___ and ___. Both being difficult secondary to having large babies and history of gestational diabetes. Her last Pap was normal. She denies any history of abnormal Pap smears and since she has had a total abdominal hysterectomy, there is no need for any further Paps. She denies any history of sexually transmitted infections. However, she has had genital ulcers related to Behcet's syndrome. PAST MEDICAL HISTORY: Significant for Behçet's syndrome, thrombophlebitis, migraine headaches, anemia, diabetes, hypertension, kidney stones, depression, joint disease, chronic pain syndrome, lumbar spondylosis, and lumbar degenerative disc disease. <SOCIAL HISTORY> ___ <FAMILY HISTORY> FAMILY HISTORY: Significant for uncle with stomach cancer, cousin with breast cancer who died at age ___ on the maternal side of the family. She has a brother with ___ disease, hypertension, and kidney disease in the family as well. She denies any history of uterine, cervical, colon, or ovarian cancer. <PHYSICAL EXAM> Gen: patient appears in pain, moving around on stretcher CV: RRR, S1S2 Pulm: CTAB Abd: obese, soft, +BS, ileostomy in RLQ, 2 well healed ___ incisions, tenderness to light palpation over left lateral aspect of most recent incision, no guarding and no rebound Ext: NT, + distal pulses <PERTINENT RESULTS> ___ 08: 19PM WBC-10.3 RBC-4.05* HGB-13.4 HCT-38.5 MCV-95 MCH-33.0* MCHC-34.7 RDW-13.9 ___ 08: 19PM NEUTS-54.6 ___ MONOS-6.1 EOS-3.1 BASOS-0.4 ___ 08: 19PM GLUCOSE-97 UREA N-15 CREAT-0.8 SODIUM-140 POTASSIUM-5.1 CHLORIDE-106 TOTAL CO2-19* ANION GAP-20 ___ 08: 19PM CALCIUM-9.8 PHOSPHATE-3.2 MAGNESIUM-2.1 ___ 11: 24PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5 LEUK-NEG ___ 11: 24PM URINE RBC-2 WBC-1 BACTERIA-NONE YEAST-NONE EPI-15 ___ 11: 24PM URINE COLOR-Straw APPEAR-Clear SP ___ <MEDICATIONS ON ADMISSION> Lomotil 4 Tabs in am and 4 tabs in pm Cymbalta 60mg Daily Dilaudid 8mg Po Q4 PRN Ativan 1mg PRN Zofran 4mg PRN Percocet ___ Q6 PRN Protonix 40mg BID Ambien 10mg QHS <DISCHARGE MEDICATIONS> 1. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 2. Duloxetine 30 mg Capsule, Delayed Release(E.C.) Sig: Two (2) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 3. Diphenoxylate-Atropine 2.5-0.025 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 4. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp: *60 Capsule(s)* Refills: *0* 5. Bethanechol Chloride 5 mg Tablet Sig: Two (2) Tablet PO QID (4 times a day). Disp: *225 Tablet(s)* Refills: *0* 6. Hydromorphone 2 mg Tablet Sig: ___ Tablets PO Q3H (every 3 hours) as needed for pain. Disp: *45 Tablet(s)* Refills: *0* 7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation. Disp: *50 Capsule(s)* Refills: *0* 8. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> Chronic pain <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. **if no cervix p LSC hyst, nothing in vagina for 3 months * You may eat a regular diet.
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Pt was admitted for ___ LLQ abdominal pain. An abdominal CT on the evening of admission could not identify any etiology for her pain. There was no neuroma or abscess as identified by the CT scan. She was given a Dilaudid PCA and seen by the chronic pain service. They suggested increasing the Dilaudid PCA, as well as a trigger point injection into her scar site with bupivacaine. Please see their consult note for full details. Given her chronic pain issues, both GYN and pain management felt that a more suitable long-term pain program was best managed by her providers in ___. As her pain remitted, she was transitioned to po Dilaudid prn and gabapentin bid. She was discharged with adequate pain control until her pre-arranged appointment with her PCP on ___ at 9:30am. During her hospitalization, the pt had symptoms of urinary retention. A foley catheter was inserted. She was given a voiding trial on HD 1. She was unable to void and a repeat Foley showed 300 cc of residual. A voiding trial was reattempted later that evening. She was able to void but with a 700cc residual as confirmed by the foley catheter re-insertion. On HD2, pt was started on Urecholine. At this time, she was able to void comfortably on her own. At the time of discharge on HD 3, pt had good po pain control, was taking adequate po's, and voiding on her own.
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11176797-DS-10
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> Fevers, Back pain <MAJOR SURGICAL OR INVASIVE PROCEDURE> Ultrasound guided drainage <HISTORY OF PRESENT ILLNESS> Ms ___ is ___ s/p robot assisted trachelectomy, right salpingo-oophorectomy, removal of left ovarian remnant, and cystoscopy,on abx for UTI, admitted on POD 8 with back pain and pelvic fluid collection concerning for abscess. <PAST MEDICAL HISTORY> HTN, hypothyroidism, anemia. Denies h/o DMII and thromboembolic disorder. PSH: ___ c/s ___ c/s ___ c/s ___ laparoscopic SCH, LSO, umbilical hernia repair ___ laparoscopic LOA ___ robotic removal of left ovarian remnant ___ laparoscopic hernia revision OB: ___, c/s x3 GYN: Menarche age ___. LMP ___ following ___. Remote history of abnormal pap smear with normal follow up. Denies h/o fibroids, ovarian cysts and STI/PID. <SOCIAL HISTORY> ___ <FAMILY HISTORY> Mother and father have HTN. Denies family history of breast cancer, ovarian cancer, endometrial cancer and colon cancer. <PHYSICAL EXAM> Physical Exam on Discharge: VSS NAD, comfortable RRR Lungs CTAB Abd soft, obese, nontender, +bs Ext warm well perfused, no tenderness to palpation <PERTINENT RESULTS> ___ 01: 25AM WBC-9.3 RBC-3.21* HGB-9.1* HCT-27.0* MCV-84 MCH-28.3 MCHC-33.6 RDW-12.9 Urine Culture: Serratia Marcescens-Cipro sensitive Abscess Culture: pending <MEDICATIONS ON ADMISSION> Lisinopril 20mg Levoxyl 125mcg HCTZ 12.5mg Cipro <DISCHARGE MEDICATIONS> 1. levothyroxine 125 mcg Tablet Sig: Two (2) Tablet PO 5 TIMES PER WEEK (). 2. lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. levothyroxine 125 mcg Tablet Sig: Three (3) Tablet PO 2 TIMES PER WEEK (). Tablet(s) 4. hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 5. metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3 times a day): Take for 12 days. Disp: *36 Tablet(s)* Refills: *0* 6. phenazopyridine 100 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day) as needed for pain for 3 days: Take for bladder pain. Disp: *24 Tablet(s)* Refills: *0* 7. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours): Take for 12 days. Disp: *24 Tablet(s)* Refills: *0* <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> UTI, back pain, possible pelvic abscess <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Dear Ms ___, You were admitted to the gynecologic oncology service for fevers and back pain and found to have suspected abscess. You have recovered well, and the team feels that you are safe to be discharged home. Please follow these instructions: General instructions: * Take your medications as prescribed. * Do not drive while taking narcotics. * Do not combine narcotic and sedative medications or alcohol * Do not take more than 4000mg acetaminophen (APAP) in 24 hrs * No strenuous activity until your post-op appointment * 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 ___ presented to the ED on post op day 8 from robot assisted trachelectomy, right salpingo-oophorectomy, removal of left ovarian remnant, and cystoscopy,on abx for UTI, with back pain and pelvic fluid collection concerning for abscess. She presented to the ED two days prior with fevers, abdominal pain, and painful urination and was found to have a UTI, cultures + for Serratia marcescens, at that time she was discharged home with cipro. On representation MS ___ had a CT and a 4cm loculated fluid collection suspicious for abscess was found. Ms ___ was sent for ultrasound guided transvaginal drainage of suspected abscess on hospital day 1. During the procedure 6cc of serosagenous fluid was drained and sent for culture. On hospital day 2 patient felt much improved, pain well controlled, tolerating PO, and felt comfortable and safe going home. She was discharged on a 14 day course of cipro and flagyl.
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11176797-DS-9
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> cyclical pelvic pain associated with N/V. <MAJOR SURGICAL OR INVASIVE PROCEDURE> robot assisted trachelectomy, right salpingo-oophorectomy, removal of left ovarian remnant, and cystoscopy. <HISTORY OF PRESENT ILLNESS> Ms. ___ is a ___ yo with a five-year history of cyclical pelvic pain. This pain began in ___ after she underwent a laparoscopic supracervical hysterectomy, left salpingo-oophorectomy and umbilical hernia repair. The indication for this surgery was menorrhagia, and she had failed conservative treatment with IUD and an ablation. Pathology revealed adenomyosis; she had had no previous pelvic pain. She was taken back to the operating room within months for a lysis of adhesions secondary to pain. Subsequently, she underwent a robotic procedure to remove a left ovarian remnant in ___. Her pain persisted in cyclical fashion, so she was treated with Lupron for four months in ___, which alleviated her symptoms. She chose to discontinue the medication secondary to side effects. Today she complains of persistent, cyclical pain that is severe in nature and associated with nausea, vomiting, dysuria, and bloody stools, which requires her to miss work for ___ days. She denies vaginal bleeding or discharge. <PAST MEDICAL HISTORY> HTN, hypothyroidism, anemia. Denies h/o DMII and thromboembolic disorder. PSH: ___ c/s ___ c/s ___ c/s ___ laparoscopic SCH, LSO, umbilical hernia repair ___ laparoscopic LOA ___ robotic removal of left ovarian remnant ___ laparoscopic hernia revision OB: ___, c/s x3 GYN: Menarche age ___. LMP ___ following SCH. Remote history of abnormal pap smear with normal follow up. Denies h/o fibroids, ovarian cysts and STI/PID. <SOCIAL HISTORY> ___ <FAMILY HISTORY> Mother and father have HTN. Denies family history of breast cancer, ovarian cancer, endometrial cancer and colon cancer. <PHYSICAL EXAM> on discharge: VS: AVSS Gen: NAD Card: RRR Lungs: CTAB Abd: soft, non-distended, +BS, incisions C/D/I with steri-stripes in place, no R, no G GU: min. vaginal spotting on pad; foley in place, draining clear yellow urine Ext: NTTP <PERTINENT RESULTS> ___ 06: 55AM BLOOD WBC-6.2 RBC-3.05* Hgb-8.9* Hct-25.9* MCV-85 MCH-29.0 MCHC-34.2 RDW-14.4 Plt ___ ___ 06: 55AM BLOOD Glucose-106* UreaN-9 Creat-0.7 Na-139 K-3.7 Cl-103 HCO3-28 AnGap-12 ___ 04: 40PM BLOOD WBC-8.0 RBC-3.49* Hgb-9.9* Hct-29.4* MCV-84 MCH-28.5 MCHC-33.8 RDW-13.3 Plt ___ ___ 04: 40PM BLOOD Glucose-158* UreaN-8 Creat-0.7 Na-136 K-3.7 Cl-100 HCO3-27 AnGap-13 <MEDICATIONS ON ADMISSION> Lisinopril, ibuprofen, levoxyl, hydrochlorothiazide, multivitamin <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. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp: *60 Capsule(s)* Refills: *2* 3. hydromorphone 2 mg Tablet Sig: ___ Tablets PO Q4H (every 4 hours) as needed for pain. Disp: *45 Tablet(s)* Refills: *0* 4. nitrofurantoin monohyd/m-cryst 100 mg Capsule Sig: One (1) Capsule PO DAILY (Daily) for 6 days. Disp: *6 Capsule(s)* Refills: *0* 5. acetaminophen 500 mg Tablet Sig: ___ Tablets PO Q6H (every 6 hours) as needed for pain: Do not take more than 4000 mg of acetaminophen within 24 hrs. . Disp: *50 Tablet(s)* Refills: *0* 6. hydrochlorothiazide 12.5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. lisinopril 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 8. levothyroxine 125 mcg Tablet Sig: Two (2) Tablet PO 5X/WEEK (___). 9. levothyroxine 125 mcg Tablet Sig: Three (3) Tablet PO 2X/WEEK (___). <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> Pelvic pain <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Dear ___ You were admitted to the gynecologic oncology service after undergoing the procedures listed below. You have recovered well after your operation, and the team feels that you are safe to be discharged home. Please follow these instructions: General instructions: * Leave the Foley catheter in place and follow the instructions provided by your nurses. ___ foley will be removed on your ___. appointment. * Take your medications as prescribed. * Do not drive while taking narcotics. * Do not combine narcotic and sedative medications or alcohol * Do not take more than 4000mg acetaminophen (APAP) in 24 hrs * No strenuous activity until your post-op appointment * Nothing in the vagina (no tampons, no douching, no sex) for 3 months * No heavy lifting of objects >10 lbs for 6 weeks. * You may eat a regular diet Incision care: * You may shower and allow soapy water to run over incision; no scrubbing of incision. No bath tubs for 6 weeks. * You have steri-strips, leave them on. If they are still on after ___ days from surgery, you may remove them. -Please follow up with your primary care physician for your anemia (you had anemia prior to this surgery) in the setting of absent of monthly menstrual cycle. To reach medical records to get the records from this hospitalization sent to your doctor at home, call ___.
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Patient underwent scheduled robot assisted trachelectomy, lysis of adhesions, right salpingo-oophorectomy, removal of left ovarian remnant, and cystoscopy for her cyclical pelvic pain. The surgery was uncomplicated. Please see ___ note for details. Pt was then admitted for routine postoperative care. Patient's pain was well controlled on IV dilaudid/toradol which was transitioned to PO percocet/ibuprofen. Due to the nature of the surgery and extensive dissection close to the bladder, the foley catheter will stay in patient for 1 week. While the foley is in place, pt will receive prophylactic Macrobid. By postop day 1, patient had advanced her diet to PO solids, had gotten out of bed and did not have CP/SOB/N/V/calf pain. Patient restarted her hypertension and hypothyroid medications the morning of postop day 1. Patient was discharged on POD#2 in stable condition and was instructed to call if any questions arise.
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