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10001725-DS-12
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Codeine / gabapentin / morphine / Amoxicillin / metronidazole / propoxyphene / rofecoxib / Macrobid / furosemide / Amitiza / Sulfa (Sulfonamide Antibiotics) / Tylenol / Hydromorphone / Toradol <ATTENDING> ___ <CHIEF COMPLAINT> For admission: elective gynecologic surgery for urinary retention For MICU transfer: Anaphylaxis <MAJOR SURGICAL OR INVASIVE PROCEDURE> Stage 2 interstim w/ posterior colporrhaphy for rectocele + enterocele ___ <HISTORY OF PRESENT ILLNESS> <HISTORY OF PRESENT ILLNESS> Ms. ___ is a ___ w/ Hx of cervical CA s/p radical hysterectomy c/b chronic ___ lymphedema and urinary retention, for which she frequently self-caths, Asthma, GERD, IBS, anxiety/depression, fibromyalgia and other issues who was admitted for an elective gynecologic surgery (stage 2 interstim and posterior colporrhaphy w/ graft) for urinary retention and rectocele + enterocele. <PAST MEDICAL HISTORY> Cervical CA s/p radical hysterectomy c/b chronic ___ lymphedema ADHD Anxiety/Depression Asthma Insomnia GERD Raynaud's IBS Fibromyalgia <SOCIAL HISTORY> ___ <FAMILY HISTORY> +Hx of atopy in son, daughter; both w/ frequent allergy rxns requiring epi pens <PHYSICAL EXAM> MICU ADMISSION EXAM: -------------------- Vitals: T: 98.7 BP: 113/83 P: 79 R: 18 O2: 97% ___ ___: Well appearing female in no acute distress, slightly muffled voice, somewhat flushed skin HEENT: Moist mucous membranes, mild lip swelling, tongue not grossly edematous, no angioedema Neck: JVP non elevated CV: Regular rate and rhythm, normal S1 S2, no murmurs Lungs: Clear to auscultation bilaterally, no wheezes/rales/rhonchi Abdomen: Soft, normoactive bowel sounds, nontender, nondistended, no rebound or guarding GU: Foley in place Ext: Warm, trace ___ edema, peripheral pulses 2+ ___ Neuro: alert and oriented to person, hospital, and date MICU DISCHARGE EXAM: -------------------- Vitals: T: 97.5 BP: 107/62 P: 84 R: 16 O2: 99% ___ ___: Well appearing female in no acute distress, normal voice, somewhat flushed skin, most prominent in malar distribution on face HEENT: Moist mucous membranes, appearance of face unchanged from yesterday, tongue not edematous, no angioedema Neck: JVP non elevated CV: Regular rate and rhythm, normal S1 S2, no murmurs Lungs: Clear to auscultation bilaterally, no wheezes/rales/rhonchi Abdomen: Soft, normoactive bowel sounds, nontender, nondistended, no rebound or guarding GU: Foley in place Ext: Warm, trace ___ edema, peripheral pulses 2+ ___ Neuro: alert and oriented to person, hospital, and date GYN Floor discharge exam: VSS, AF Gen: NAD A&O x 3 Resp: no visible respiratory distress, speaking in full sentences Abd: soft, NT ND Ext: moving all 4 extremities <PERTINENT RESULTS> MICU ADMISSION LABS: ___ 06: 02PM BLOOD WBC-17.0* RBC-4.33 Hgb-13.9 Hct-39.1 MCV-90 MCH-32.2* MCHC-35.6* RDW-11.8 Plt ___ ___ 06: 02PM BLOOD Neuts-94.5* Lymphs-4.3* Monos-0.7* Eos-0.1 Baso-0.3 ___ 06: 02PM BLOOD ___ PTT-31.8 ___ ___ 06: 02PM BLOOD Glucose-146* UreaN-16 Creat-0.8 Na-140 K-3.9 Cl-106 HCO3-24 AnGap-14 ___ 06: 02PM BLOOD Calcium-9.1 Phos-3.1 Mg-1.5* ___ 06: 02PM BLOOD TRYPTASE-PND MICU DISCHARGE LABS: ___ 02: 59AM BLOOD WBC-20.1* RBC-3.98* Hgb-12.6 Hct-36.3 MCV-91 MCH-31.6 MCHC-34.7 RDW-11.9 Plt ___ ___ 02: 59AM BLOOD Plt ___ ___ 02: 59AM BLOOD Glucose-152* UreaN-18 Creat-0.8 Na-138 K-3.5 Cl-102 HCO3-24 AnGap-16 ___ 02: 59AM BLOOD Calcium-9.1 Phos-4.0 Mg-2.8* PERTINENT LABS: ___ 06: 02PM BLOOD WBC-17.0* RBC-4.33 Hgb-13.9 Hct-39.1 MCV-90 MCH-32.2* MCHC-35.6* RDW-11.8 Plt ___ ___ 06: 02PM BLOOD Neuts-94.5* Lymphs-4.3* Monos-0.7* Eos-0.1 Baso-0.3 ___ 06: 02PM BLOOD ___ PTT-31.8 ___ ___ 06: 02PM BLOOD Glucose-146* UreaN-16 Creat-0.8 Na-140 K-3.9 Cl-106 HCO3-24 AnGap-14 ___ 06: 02PM BLOOD Calcium-9.1 Phos-3.1 Mg-1.5* ___ 06: 02PM BLOOD TRYPTASE-PND PERTINENT IMAGING: None PERTINENT MICRO: None <MEDICATIONS ON ADMISSION> Albuterol sulfate 2.5 mg/3 mL (0.083 %) Neb TID PRN Albuterol ProAir HFA 90 mcg INH 1 puff BID PRN Cephalexin 250 mg Q6H Adderall XR 15 mg BID Ergocalciferol (vitamin D2) 50,000 U Q week Nexium 40 mg ___ QAM Vivelle 0.075 mg/24 hr Transderm Patch 2x / week Diflucan 200 mg Q ___ Hydroxyzine HCl 25 mg QD PRN Ibuprofen 600 mg Q8H PRN Linzess (linactolide) 145 mcg QD Ativan 1 mg QD PRN Metolazone 2.5 mg QD Zofran 8 mg PO PRN Oxycodone 5 mg PO Q6H PRN Potassium chloride 10 % Oral Liquid 30ml PO QID Propranolol ER 80 mg ER QHS Spironolactone 100 mg QD Trimethoprim 100 mg tablet QD Ambien 10 mg QHS #14 ___ catheter Docusate sodium 100 mg BID LACTOBACILLUS COMBINATION <DISCHARGE MEDICATIONS> 1. Docusate Sodium (Liquid) 100 mg PO BID RX *docusate sodium 100 mg 1 tablet by mouth twice a day Disp #*60 Capsule Refills: *0 2. Bisacodyl 10 mg PO/PR DAILY: PRN Constipation RX *bisacodyl 5 mg ___ tablet,delayed release (___) by mouth constipation Disp #*20 Tablet Refills: *0 3. Metolazone 2.5 mg PO DAILY 4. NexIUM (esomeprazole magnesium) 40 mg Oral once Duration: 1 Dose 5. OxycoDONE (Immediate Release) ___ mg PO Q6H: PRN pain do not drive and drink on this medication RX *oxycodone 5 mg ___ tablet(s) by mouth every 6 hrs Disp #*20 Tablet Refills: *0 6. Propranolol LA 80 mg PO DAILY 7. Spironolactone 100 mg PO DAILY 8. Zolpidem Tartrate 5 mg PO HS 9. Trimethoprim 100 mg PO DAILY 10. Vivelle (estradiol) 0.075 mg/24 hr Transdermal twice/week 11. Lorazepam 1 mg PO DAILY: PRN anxiety 12. Potassium Chloride 40 mEq PO DAILY Duration: 24 Hours Hold for K > <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> urinary retention, rectocele <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Dear ___, You were admitted to the Gynecology service after your scheduled Stage 2 Insterstim placement and posterior colporrhaphy with graft for urinary retention and rectocele and enterocele. You tolerated the procedure well. However, after your operation, you had a severe allergic reaction, and had to go to the ICU for monitoring. Since then, you have recovered well, and we have determined that you are in stable condition for discharge. Please take your medication and follow-up at your appointments as scheduled. ___ instructions: * Take your medications as prescribed. * Do not drive while taking narcotics. * Take a stool softener such as colace while taking narcotics to prevent constipation * Do not combine narcotic and sedative medications or alcohol * Do not take more than 4000mg acetaminophen (APAP) in 24 hrs * No strenuous activity until your post-op appointment * Nothing in the vagina (no tampons, no douching, no sex) for 6 weeks * No heavy lifting of objects >10lbs for 6 weeks. * You may eat a regular diet * or anything that concerns you 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 * or anything that concerns you To reach medical records to get the records from this hospitalization sent to your doctor at home, call ___.
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Ms. ___ is a ___ y/o F w/ Hx of cervical CA s/p radical hysterectomy c/b chronic ___ lymphedema and urinary retention, Asthma, GERD, anxiety/depression, fibromyalgia. Please refer to the operative report for full details. Her post-operative course was uncomplicated. Immediately post-op, her pain was controlled with IV dilaudid and toradol. However, in the PACU, the patient started feeling itchy. Once the pt returned to the floor, she noted sensation of tongue / lip swelling, difficulty swallowing secretions, and a change in her voice. No SOB, no flushing, no stridor or wheeze. She was administered an Epi-pen, Solumedrol 100 mg IV, Famotidine 20 mg IV, and Hydroxyzine 25 mg IM. She was transferred to the MICU for closer monitoring. The patient has numerous drug allergies and was administered the following medications intra-operatively: Midazolam, Rocuronium, Fentanyl, Dexamethasone, Hydromorphone, Ondansetron, Lidocaine, Propofol, Cefazolin, Glycopyrrolate, Phenylephrine, and Ketorolac. In the MICU, initial VS were HR 87, BP 100/63, RR 17, S 100% ___. The patient was in NAD, without wheeze or poor air movement on exam, but complained of persistent voice change and difficulty swallowing, for which she required 2 more epi pens. Has remained hemodynamically stable and without respiratory compromise. ACTIVE ISSUES: *) Post operative care Her pain was controlled immediately post-op with IV dilaudid and toradol. This was transitioned to po oxycodone as it was difficult to determine what was causing an allergic reaction in Ms. ___. Her vaginal packing was removed on POD 1, on post-operative day 2, her urine output was adequate and her Foley was removed. The patient was able to void spontaneously, but did require self-catheterization ___ times a day based on a sensation of bladder fullness. *) Anaphylaxis: In the PACU the patient awoke and started feeling pruritis. Once she arrived to the floor, the patient noted difficulty talking, subjectively swollen lips/tongue, and vocal changes. No SOB, no flushing, no stridor or wheeze. A trigger was called for anaphyllaxis and she recieved an Epi-pen, Solumedrol 100 mg IV, Famotidine 20 mg IV, and Hydroxyzine 25 mg IM. She was transferred to the MICU for closer monitoring. In the MICU, initial VS were HR 87, BP 100/63, RR 17, S 100% ___. The patient was in NAD, without wheeze or poor air movement on exam, but complained of persistent voice change and difficulty swallowing, for which she required 2 more epi pens. Has remained hemodynamically stable and without respiratory compromise. Of note, patient was lying comfortable in bed around 2200 and continuing to inquire about more Epi-pens vs epinephrine gtt despite comfortable respiration, vocalization, non-edematous oral structures. She also perseverated about her Ativan and Ambien, as well as her propranolol for essential tremor despite explanation that beta blockers can worsen bronchoconstriction and respiratory compromise in anaphylaxis. On the day she was called out to the floor, the pt complained of persistent facial flushing. She was afebrile, hemodynamically stable, and without respiratory compromise or systemic symptoms. Symptomatic care with hydroxyzine and eucerin lotion was provided. Upon step down to the floor, the patient again reported to nursing that she felt throat constriction. Epinephrine and solumedrol were given and the patient felt relief. Allergy was consulted, and they asked us to stop all new medications given to her while at the hospital, and to report all of them as allergies. In addition, we sent out a tryptase level, as well as coordinated outpatient follow-up with them. #Chronic ___ edema: Continue home Metolazone, spironolactone, potassium repletion as not hypotensive. We monitored her K during her stay, which was WNL. #Asthma: Home Albuterol use ___ per week, did not require in the MICU. #GERD: Nexium (was initially held on admission, but per pt request was given on ___ prior to advancing diet) #ADHD: On Adderall, held on admission # Anxiety/depression/fibromyalgia: lorazepam # Insomnia: zolpidem By post-operative day 1, she was tolerating a regular diet, ambulating independently, and pain was controlled with oral medications. She was the discharged home in stable condition with outpatient follow-up scheduled. She was also scheduled to have an appointment with Allergy and Immunology.
| 2,395 | 1,058 |
10002800-DS-15
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Percocet / cucumber / Tegaderm <ATTENDING> ___. <CHIEF COMPLAINT> cracked tooth, s/p fall <MAJOR SURGICAL OR INVASIVE PROCEDURE> tooth extraction <HISTORY OF PRESENT ILLNESS> Patient is a ___ year old G1P0 at ___ by U/S w/ h/o breast CA on DDAC chemotherapy in pregnancy and thyroid CA who presents after transfer from ED for tooth pain and for evaluation after a fall two days ago when she tripped on the ice and hit her shoulder. She reports progressive dental pain in the right lower molar. She has been unable to get dental treatment of her fractured molar in the outpatient setting due to concerns about pregnancy and medical complexity. She was therefore referred to the ED. OMFS was consulted while she was in the ED w/ plan for removal in the OR tomorrow. Findings included cracked tooth #29 w/ carriers extending to pulp. The patient was sent to OB triage given the mechanical fall. The patient denies any abdominal trauma or bruising. She has been having very irregular cramping, no contractions. She also reports intermittent sharp shooting pain from the groin to her belly button. Not exacerbated by anything. Pain cannot be reproduced. She denies and VB or LOF. <PAST MEDICAL HISTORY> PNC: - ___ ___ by US - Labs: Rh+/ab neg/RPRNR/RI/HBsAg neg/HIV neg/ GBS unknown - Genetics: LR ERA - FFS: wnl - GLT: wnl - US: ___, 67%, breech, ___, nl fluid, anterior placenta - Issues: *) breast cancer in pregnancy: unilateral mastectomy w/ sentinel LN biopsy, s/p chemotherapy completed ___, plan for PP tamoxifen *) mild asthma *) History of papillary thyroid cancer x 2, on levothyroxine 175mcg daily; labs ___ - TSH 4.3 (elevated) but normal FT4 (1.1) ROS: per hpi GYNHx: h/o breast cancer OBHx: G1, current PMH: h/o breast cancer, mild asthma, h/o papillary PSH: s/p unilateral mastectomy w/ sentinel LN biopsy <SOCIAL HISTORY> ___ <FAMILY HISTORY> Family history: Aunt and mother with ALS. Mother, aunt, grandmother: ___. Father--prostate cancer (age ___ <PHYSICAL EXAM> On admission: ___ 19: 03Temp.: 98.0°F ___ 19: 03BP: 121/65 (76) ___ ___: 69 ___ ___: 67 GEN: NAD Respiratory: no increased WOB Abdomen: no bruising, non-tender, gravid SVE: LCP TAUS: vtx, anterior placenta, no sonographic evidence of abruption, MVP 5.4 FHT: 130/moderate/+accels/ no decels On discharge: VS: 98.0, 114/71, 73, 16, O2 96% 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: ___ FHT: 120s, mod var, +accels, no decels reactive Toco: occ ctx <PERTINENT RESULTS> n/a <MEDICATIONS ON ADMISSION> albuterol, levothyroxine <DISCHARGE MEDICATIONS> Acetaminophen 1000 mg PO Q6H: PRN Pain - Mild RX *acetaminophen 500 mg ___ tablet(s) by mouth every 6 hours Disp #*50 Tablet Refills: *0 Levothyroxine Sodium 200 mcg PO DAILY <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> Cracked tooth <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Dear Ms. ___, You were admitted to the ___ service for monitoring after a fall and prior to your procedure with the oral surgeons for a tooth extraction. You procedure went well and your baby was monitored before and after the procedure. You are now stable to be discharged home. Please see instructions below. You should continue biting down on a piece of gauze for 30 minute interval. You may stop after ___ gauze changes. You should NOT have any hot/solid foods for the time being. You may continue drinking cool liquids. You may transition to soft foods (eggs, pasta, pancake) tonight. For pain control, you may take Tylenol as needed (do not take more than 4000mg in 24 hours). Please call your primary dentist with any questions or concerns. 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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Patient is a ___ year old G1 with hx of breast CA on DDAC chemotherapy in pregnancy and thyroid CA admitted at 34w2d after a fall. On admission, she had no evidence of abruption or preterm labor. She reported mild cramping and her cervix was LCP. Fetal testing was reassuring. She also had a painful, cracked tooth and had been evaluated by OMFS in the emergency room. A plan was made for extraction in the OR. On HD#2, she underwent an uncomplicated tooth extraction under local anesthesia. Her pain resolved. She continued to have some intermittent cramping and pink discharge, however, she had no evidence of preterm labor. She was discharged to home in stable condition on HD#3 and will have close outpatient follow up.
| 1,118 | 161 |
10002870-DS-14
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> Pelvic mass and uterine fibroid. <MAJOR SURGICAL OR INVASIVE PROCEDURE> Total abdominal hysterectomy, bilateral salpingo-oophorectomy. <HISTORY OF PRESENT ILLNESS> Ms. ___ is a ___, postmenopausal female, who was found to have a left-sided pelvic mass on routine exam. . Pelvic ultrasound revealed large left adnexal mass. Pelvic MRI was done which revealed a 7.9cm left ovarian mass with some imaging features suggestive a fibroma/fibrothecoma but other features atypical for this diagnosis. There was also a multi-fibroid uterus with material within the endometrial cavity at the level of the fundus. A preoperative CA-125 was 17. An endometrial biopsy showed inactive endometrium. She presents today for definitive surgical management. . She reports baseline urinary frequency, urgency, irritable bowel and abdominal bloating. She denies any vaginal bleeding or abdominal/pelvic pain. <PAST MEDICAL HISTORY> PMH: R Breast Dysplasia, Hypercholesterolemia, Anxiety, Osteoarthritis, Hypothyroidism, Herpes. PSH: L leg muscle graft, knee arthroscopy, R hand ganglion cyst removal, R thyroid lobe removal. OB/GYN: G3P1, post-menopausal, last Pap ___ no hx abnl paps, STIs, gyn dx. <SOCIAL HISTORY> ___ <FAMILY HISTORY> no h/o ovarian, breast, uterine or colon cancer. <PHYSICAL EXAM> On day of discharge: Afebrile, vitals stable General: No acute distress CV: regular rate and rhythm Pulm: clear to auscultation bilaterally Abd: soft, appropriately tender, nondistended, incision clean/dry/intact, no rebound/guarding ___: nontender, nonedematous <PERTINENT RESULTS> ___ 06: 05AM BLOOD WBC-12.1* RBC-4.01* Hgb-12.7 Hct-37.8 MCV-94 MCH-31.8 MCHC-33.7 RDW-14.7 Plt ___ ___ 06: 05AM BLOOD Neuts-71.7* ___ Monos-5.6 Eos-1.9 Baso-0.5 ___ 06: 05AM BLOOD Plt ___ ___ 06: 05AM BLOOD Glucose-100 UreaN-11 Creat-0.6 Na-139 K-4.4 Cl-104 HCO3-28 AnGap-11 ___ 06: 05AM BLOOD Calcium-8.0* Phos-3.2 Mg-1.9 <MEDICATIONS ON ADMISSION> hydrocodone 5 mg-acetaminophen 325 mg PO QID ibuprofen 800 mg PO BD prn pain levothyroxine 100 mcg, 1 tablet QD for 5 days, 1.5 tablets for 2 days/wk sertraline 100 mg, PO, QD simvastatin 40 mg, PO, QD valacyclovir 500 mg, PO, BD for 4 days prn breakout <DISCHARGE MEDICATIONS> 1. 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 2. Docusate Sodium 100 mg PO BID Take to prevent constipation while taking narcotics. RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day Disp #*60 Capsule Refills: *1 3. Levothyroxine Sodium 150 mcg PO 2X/WEEK (MO,FR) 4. Levothyroxine Sodium 100 mcg PO 5X/WEEK (___) 5. Sertraline 100 mg PO DAILY 6. Oxycodone-Acetaminophen (5mg-325mg) ___ TAB PO Q4H: PRN pain Do not exceed 4000 mg of acetaminophen in 24h. Do not drive. RX *oxycodone-acetaminophen 5 mg-325 mg ___ tablet(s) by mouth every four (4) hours Disp #*60 Tablet Refills: *0 <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> Benign ovarian fibroma and fibroid uterus. <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Dear Ms. ___, You were admitted to the gynecologic oncology service after undergoing the procedures listed below. You have recovered well after your operation, and the team feels that you are safe to be discharged home. Please follow these instructions: * Take your medications as prescribed. * Do not drive while taking narcotics. * Do not combine narcotic and sedative medications or alcohol. * Do not take more than 4000mg acetaminophen (APAP) in 24 hrs. * No strenuous activity until your post-op appointment. * Nothing in the vagina (no tampons, no douching, no sex) for 12 weeks. * No heavy lifting of objects >10 lbs for 6 weeks. * You may eat a regular diet. * It is safe to walk up stairs. . Incision care: * You may shower and allow soapy water to run over incision; no scrubbing of incision. No bath tubs for 6 weeks. To reach medical records to get the records from this hospitalization sent to your doctor at home, call ___.
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Ms. ___ ___ was admitted to the gynecologic oncology service after undergoing total abdominal hysterectomy, bilateral salpingo-oophorectomy, and washings. Please see the operative report for full details. . Her post-operative course is detailed as follows. Immediately postoperatively, her pain was controlled with IV Dilaudid/Toradol. Her diet was advanced without difficulty and she was transitioned to PO Oxycodone and Ibuprofen. On post-operative day #1, her urine output was adequate so her Foley catheter was removed and she voided spontaneously. . By post-operative day #1, she was tolerating a regular diet, voiding spontaneously, ambulating independently, and pain was controlled with oral medications. She was then discharged home in stable condition with outpatient follow-up scheduled.
| 1,299 | 166 |
10004296-DS-11
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Sulfamethoxazole / Penicillins <ATTENDING> ___. <CHIEF COMPLAINT> arrest of descent, gHTN, incisional cellulitis with wound abscess <MAJOR SURGICAL OR INVASIVE PROCEDURE> primary low transverse cesarean section <HISTORY OF PRESENT ILLNESS> Patient is a ___ year-old G3P0 with EDC = ___ (EGA = 37w1d on ___ with elevated blood pressures in the office as high as 140/70 over the past week. Repeat BP in OB triage = 142/70, 141/72, 139/85. PIH labs on ___ showed: CBC 15.6 > 10.6 / 30.3 < 312 ALT 21 Cr 0.5 Uric Acid 5.0 UP: C 0.1 She currently denies headache, visual changes, epigastric or RUQ pain. Denies ctx, VB, LOF. +FM <PAST MEDICAL HISTORY> MEDICAL HISTORY Allergies (Last Verified ___ by ___: Penicillins Sulfamethoxazole --------------- --------------- --------------- --------------- Active Medication list as of ___: Medications - Prescription ALBUTEROL SULFATE [PROAIR HFA] - ProAir HFA 90 mcg/actuation aerosol inhaler. 2 puffs every four (4) hours PRN BUDESONIDE-FORMOTEROL [SYMBICORT] - Symbicort 160 mcg-4.5 mcg/actuation HFA aerosol inhaler. 2 puffs inh twice a day PNV WITH CALCIUM ___ [PRENATAL VITAMINS LOW IRON] - Dosage uncertain - (Prescribed by Other Provider) Medications - OTC DOCUSATE SODIUM - docusate sodium 100 mg capsule. 1 capsule(s) by mouth once per day, as needed, for constipation --------------- --------------- --------------- --------------- Problems (Last Verified ___ by ___, MD): ASTHMA, EXTRINSIC W/ ACUTE EXACERBATION 493.02 ECZEMATOUS DERMATITIS H/O TOBACCO USE 305.1 Surgical History (Last Verified ___ by ___, MD): Surgical History updated, no known surgical history. Family History (Last Verified ___ by ___, MD): Relative Status Age Problem Comments Other ASTHMA V17.5 F/H GI MALIGNANCY V16.0 <SOCIAL HISTORY> ___ <FAMILY HISTORY> NC <PHYSICAL EXAM> VSS Gen: NAD Lungs: CTA CV: RRR Abd: 2cm opening on right side of incision with packing, erythema improved from prior, no pus Ext: 1+ pitting edema bilaterally with no calf tenderness <MEDICATIONS ON ADMISSION> The Preadmission Medication list is accurate and complete. 1. Prenatal Vitamins 1 TAB PO DAILY 2. Docusate Sodium 100 mg PO DAILY: PRN constipation 3. Symbicort (budesonide-formoterol) 160-4.5 mcg/actuation inhalation 2 puffs bid 4. ProAir HFA (albuterol sulfate) 90 mcg/actuation 2 puffs Q4H: PRN wheezing <DISCHARGE MEDICATIONS> 1. Albuterol Inhaler 2 PUFF IH Q4H: PRN asthma 2. Docusate Sodium 100 mg PO BID: PRN Constipation RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice a day Disp #*40 Capsule Refills: *1 3. Ibuprofen 600 mg PO Q6H: PRN Pain RX *ibuprofen 600 mg 1 tablet(s) by mouth every 6 hours Disp #*30 Tablet Refills: *0 4. Symbicort (budesonide-formoterol) 160-4.5 mcg/actuation inhalation BID 5. Clindamycin 450 mg PO Q6H Duration: 10 Days RX *clindamycin HCl 150 mg 3 capsule(s) by mouth every 6 hrs Disp #*108 Capsule Refills: *0 6. Ferrous Sulfate 325 mg PO BID RX *ferrous sulfate 140 mg (45 mg iron) 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills: *1 7. HYDROmorphone (Dilaudid) ___ mg PO Q4H: PRN pain RX *hydromorphone [Dilaudid] 2 mg ___ tablet(s) by mouth q4hrs Disp #*30 Tablet Refills: *0 8. Labetalol 300 mg PO BID RX *labetalol 300 mg 1 tablet(s) by mouth twice a day Disp #*40 Tablet Refills: *0 9. Prenatal Vitamins 1 TAB PO DAILY 10. ProAir HFA (albuterol sulfate) 90 mcg/actuation 2 PUFFS Q4H: PRN wheezing <DISCHARGE DISPOSITION> Home With Service Facility: ___ <DISCHARGE DIAGNOSIS> primary low transverse cesarean section gestational hypertension asthma arrest of descent endometritis, cellulitis, wound infection <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 no heavy lifting or driving x 2 weeks keep incision clean and dry
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The patient is a ___ G3, P0 at 37 weeks 4 days admitted for induction of labor due to gestational hypertension. After a prolonged induction, the patient progressed to fully dilated and +2 station. However, after 5 hours fully dilated and ___ hours pushing, there was no descent of the fetal head and significant caput was noted. The patient was recommended to undergo delivery via cesarean section. She experienced a PPH with EBL 1200cc from cervical extension, but remained stable postpartum. In terms of her gestational hypertension, she had normal labs. She was started on labetalol 200mg BID on ___, which was increased to 300mg BID on ___ for elevated pressures. During her postpartum course she developed an incisional cellulitis with wound abscess. She was noted to have erythema and induration on right side of incision and extending to mons. She was started on IV gent/clinda -> PO clindamycin started ___ ___, 10d course. She incision was opened at bedside ___ and she underwent BID wet to dry dressing changes. She had a wound culture with mixed flora, a negative urine culture, and blood cultures with no growth. Patient also experienced bilateral lower extremity edema during her stay that she found very bothersome. She received Lasix 20mg PO x1, with improvement of symptoms. She was also maintained on Lovenox 40mg daily. She was discharged on ___ in stable condition with plan for outpatient ___ for BID dressing changes and blood pressure monitoring.
| 1,284 | 330 |
10004365-DS-7
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Sulfasalazine <ATTENDING> ___. <CHIEF COMPLAINT> Pelvic pain, ruptured ectopic pregnancy <MAJOR SURGICAL OR INVASIVE PROCEDURE> L/s as above. <HISTORY OF PRESENT ILLNESS> 37 g2po (tab1) presents as transfer from ___ for early pregnancy, ___ constant LLQ. Pt s/p RSO. U/s demonstrated enlarged hyperstimulated left ovary w/ nl flow. S/p IVF, VOR ___, UT ___ embryos transferred. <PAST MEDICAL HISTORY> GYN: IF, ovarian cysts PMH: None PSH: L/S, RSO, for ovarian cyst, ___ MEDS: none ALL: sulfa -hives <SOCIAL HISTORY> ___ <FAMILY HISTORY> Noncontributory <PHYSICAL EXAM> VSS at ED. BP 100/60, P70. Appeared in no distress.COR RRR, PULM CTAB, abd mildly distended, moderately tender, no rbnd, no guarding. Ext w/o edema. <PERTINENT RESULTS> Hct 29% (down from 37%). Labs otherwise unremarkable. TV u/s, preliminary read: Left adnexal mass likely hematoma adjacent to the massive left ovary (hyperstimulated). Single viable intrauterine gestation (7wks), a second intrauterine ___ is nonviable. <MEDICATIONS ON ADMISSION> None <DISCHARGE MEDICATIONS> 1. Polysaccharide Iron Complex ___ mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp: *60 Capsule(s)* Refills: *2* 2. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed. Disp: *0 Tablet(s)* Refills: *0* 3. Oxycodone-Acetaminophen ___ mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed. Disp: *30 Tablet(s)* Refills: *0* <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> Ruptured heterotopic pregnancy with concomittant intrauterine pregnancy. <DISCHARGE CONDITION> Excellent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Activity as tolerated; Niferex 2x day; Tylenol as needed.
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PREOP DX: Pelvic pain, possible ruptured heterotopic pregnancy vs ruptured adnexal cyst POST OP DX: Ruptured left tubal ectopic pregnancy PROCEDURE: Operative l/s, removal of EP, left salpngectomy ___ ASST: ___: Gen FINDINGS: 1- 150 cc hemoperitoneum 2- 150 cc clot 3- Left FT - ruptured an bleeding at ventral surface ampulla with surrounding clot and presumed gestational tissue. 4 - Enlarged hyperstimulated left ovary w/ normal and vascularized appearance before, during and at the end of case 5 - Surgically absent right FT and ovary 6 - Adhesions of large bowel to LLQ side wall 7 -Enlarged uterus c/w 7 wks GA IVF: ___ cc; 500 cc Hespan U/O:330 cc EBL:350 COMPLICATIONS: none SPECIMEN: Left FT, EP, clot DISPO: Stable to PACU INPATIENT NOTE - ___ SUMMARY Pt seen at ___ontrolled, DTV, no specific complaints. VSS w/ BP 100-110/ 50-60, p70. Exam w/ clear lungs, regular HR, abd mildly distended, mildly tender, incision C/d/i though ecchymosis noted at ___ port site. Labs notalble for : HCT 5 AM 19.7 9 AM 22.4 1PM 21.1 6PM 20 Diet advanced once Hct determined to be stable. TV u/s to be done bedside by residents to assess IU pregnancy viabilit
| 559 | 346 |
10004638-DS-20
|
<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Phenothiazines / Epinephrine / ppi / Nitrous Oxide <ATTENDING> ___ <CHIEF COMPLAINT> urinary frequency and urgency <MAJOR SURGICAL OR INVASIVE PROCEDURE> robotic sacrocolpopexy Tension free vaginal tape Cystoscopy <HISTORY OF PRESENT ILLNESS> Ms. ___ presented for evaluation of urinary complaints and after review of records and cystocopy was diagnosed with a stage III cystocele and stage I vaginal prolapse, both of which were symptomatic. She also had severe vaginal atrophy despite being on Vagifem. Treatment options were reviewed for prolapse including no treatment, pessary, and surgery. She elected for surgical repair. All risks and benefits were reviewed with the patient and consent forms were signed. <PAST MEDICAL HISTORY> PAST MEDICAL HISTORY: 1. Breast cancer survivor, diagnosed in ___, status post mastectomy, chemotherapy, and tamoxifen treatment. 2. Anxiety. 3. Arthritis. 4. Acid reflux. 5. Low back pain. 6. Osteopenia. 7. Vaginal prolapse. PAST SURGICAL HISTORY: 1. Modified radical mastectomy with reconstruction in ___. 2. Vaginal hysterectomy and bilateral salpingo-oophorectomy in ___ for prolapse, Dr. ___ at ___. PAST OB HISTORY: Twelve number of pregnancies, three number of vaginal deliveries, two number of living children, two number of miscarriages, birth weight of largest baby delivered vaginally 7 pounds 2 ounces, positive for forceps-assisted vaginal delivery, negative for vacuum-assisted vaginal delivery. Menopause: Surgical menopause in ___. <SOCIAL HISTORY> ___ <FAMILY HISTORY> Mother, heart disease and mitral valve prolapse; father, esophageal cancer; maternal grandfather, asthma; paternal grandmother, stomach cancer. <PHYSICAL EXAM> On postoperative check: VS 97.6 106/70 72 18 100% on 1.5L NC OR/PACU I/O 100PO + 2550 IVF / 420UOP + EBL 100 A+O, NARD RRR, CTAB Abd soft, obese, no TTP, +BS, no R/G Robot port sites with surrounding ecchymosis (all ~2cm in diameter) Dermabond intact, well approximated without erythema/exudate Pad with minimal VB Foley with CYU Ext NT, pboots on <PERTINENT RESULTS> ___ 07: 32AM BLOOD WBC-5.3 RBC-3.73* Hgb-10.9* Hct-33.1* MCV-89 MCH-29.1 MCHC-32.8 RDW-13.0 Plt ___ <MEDICATIONS ON ADMISSION> clonazepam 0.5 TID prn, ibandronate 150 q month, naratriptan 2.5 prn h/a, simvastatin 40', sucralfate 1g TID, ASA (held), vagifem, vitamins allergies: phenothyazides, compazine (anaphy) <DISCHARGE MEDICATIONS> 1. clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) as needed for pt request. 2. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. sucralfate 1 gram Tablet Sig: One (1) Tablet PO TID (3 times a day). 4. ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. Disp: *40 Tablet(s)* Refills: *0* 5. oxycodone-acetaminophen ___ mg Tablet Sig: ___ Tablets PO Q6H (every 6 hours) as needed for pain: do not exceed 12 tabs in any 24 hr period. do not take if dizzy or lightheaded. Disp: *20 Tablet(s)* Refills: *0* 6. acetaminophen 500 mg Tablet Sig: ___ Tablets PO Q6H (every 6 hours) as needed for pain or pt request. 7. 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* <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> ___ <DISCHARGE INSTRUCTIONS> - Please call your doctor if you experience fever > 100.4, chills, nausea and vomiting, worsening or severe abdominal pain, heavy vaginal bleeding, chest pain, trouble breathing, or if you have any other questions or concerns. - Please call if you have redness and warmth around the incisions, if your incisions are draining pus-like or foul smelling discharge, or if your incisions reopen. - No driving while taking narcotic pain medication as it can make you drowsy. - No heavy lifting or strenuous exercise for 6 weeks to allow your incision to heal adequately. - Nothing per vagina (no tampons, intercourse, douching for 6 weeks. - Please keep your follow-up appointments as outlined below.
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Ms. ___ underwent an uncomplicated robotic sacrocolpopexy, TVT, and cystoscopy for stage 3 pelvic organ prolapse and stress urinary incontinence; please see the operative report for full details. Her postoperative course was uncomplicated. She was discharged on postoperative day 1 in good condition after passing her trial of void and meeting all postoperative milestones.
| 1,227 | 80 |
10004638-DS-21
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Phenothiazines / Epinephrine / ppi / Nitrous Oxide / Benadryl / Protonix <ATTENDING> ___ <CHIEF COMPLAINT> rectocele <MAJOR SURGICAL OR INVASIVE PROCEDURE> posterior repair <HISTORY OF PRESENT ILLNESS> She is a ___ patient who presents with ___ rectocele after having a sacral colpopexy and supracervical hysterectomy in ___ for uterine prolapse and cystocele. At that time, she had no rectocele at all. She has symptoms of bulge and pressure in the vagina that has gotten worse over the past few months. She also complains of feeling of incomplete emptying. She states that after she goes to the bathroom, she could go back and urinate some more. She had some frequency, urgency symptoms, which had resolved postoperatively. She also has resolved diarrhea after being started on Zenpep. She is followed by Dr. ___ and her fecal incontinence has resolved as well as resolved diarrhea. <PAST MEDICAL HISTORY> <PAST MEDICAL HISTORY> She is a breast cancer survivor, anxiety, arthritis, acid reflux, low back pain, and osteopenia. Past Surgical History: Modified radical mastectomy with reconstruction in ___, vaginal hysterectomy, BSO in ___ for prolapse, Dr. ___ lysis of adhesions, ___ sacral colpopexy, cystoscopy, and TVT in ___. Past OB History: She has had three vaginal deliveries. <SOCIAL HISTORY> ___ <FAMILY HISTORY> <FAMILY HISTORY> Positive for heart disease. Mitral valve prolapse in the mother. Father with esophageal cancer. <PHYSICAL EXAM> On admission: General: Well developed, well groomed, thin. Psych: Oriented x3, affect is normal. Skin: Warm and dry. Heart: No peripheral edema or varicosities. Lungs: Normal respiratory effort. Abdomen: Soft, nontender, not distended. No masses, guarding, or rebound. No hernias. Genitourinary: Vulva: Normal hair pattern, no lesions. Urethral Meatus: No caruncle, no prolapse. Urethral meatus nontender, no masses or exudate. Bladder: Moderately atrophic. She is on vaginal estrogen with Vagifem in particular. Caliber and resting tone are normal. There is a stage III rectocele. The anterior wall and apex were extremely well supported. The bladder is nonpalpable and nontender. Cervix is absent as of the uterus and adnexa. No masses in the anus or perineum. <PERTINENT RESULTS> No labs during this hospitalization. <MEDICATIONS ON ADMISSION> BETAMETHASONE DIPROPIONATE - 0.05 % Cream - apply to affected area(s) daily as directed CLONAZEPAM - 0.5 mg Tablet - 1 (One) Tablet(s) by mouth three times a day as needed for prn ESTRADIOL [VAGIFEM] - 10 mcg Tablet - 2 twice per week for maintenence IBANDRONATE [BONIVA] - 150 mg Tablet - 1 Tablet(s) by mouth every month LIPASE-PROTEASE-AMYLASE [ZENPEP] - 20,000 unit-68,000 unit-109,000 unit Capsule, Delayed Release(E.C.) - 2 Capsule(s) by mouth with meals one with snacks SIMVASTATIN - 40 mg Tablet - 1 Tablet(s) by mouth once a day SUCRALFATE - 1 gram Tablet - 1 Tablet(s) by mouth up to four times per day SUMATRIPTAN SUCCINATE - 100 mg Tablet - 1 Tablet(s) by mouth first sign of headahce can repeat in two hours if needed ASPIRIN - (Prescribed by Other Provider) - 81 mg Tablet, Chewable - 1 (One) Tablet(s) by mouth once a day CALCIUM CARBONATE-VITAMIN D3 [CALTRATE-600 PLUS VITAMIN D3] GLUCOSAMINE ___ 2KCL-CHONDROIT [GLUCOSAMINE SULF-CHONDROITIN] MICONAZOLE NITRATE - (BID TO AFFECTED AREA) MULTI VIT W MN-FA-LYCO-LUT-ALA <DISCHARGE MEDICATIONS> 1. Clonazepam 0.5 mg PO TID: PRN anxiety 2. Ibuprofen 600 mg PO Q6H: PRN Pain RX *ibuprofen 600 mg 1 tablet(s) by mouth q8 hours Disp #*30 Tablet Refills: *2 3. Sucralfate 1 gm PO TID 4. Zenpep *NF* (lipase-protease-amylase) 20,000-68,000 -109,000 unit Oral with meals Reason for Ordering: Wish to maintain preadmission medication while hospitalized, as there is no acceptable substitute drug product available on formulary. 2 tab with meals 5. Simvastatin 40 mg PO DAILY <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> rectocele <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> 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 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 posterior repair for stage III rectocele; 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.
| 1,413 | 65 |
10004648-DS-13
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> presumed ectopic pregnancy <MAJOR SURGICAL OR INVASIVE PROCEDURE> none <HISTORY OF PRESENT ILLNESS> ___ G1 with LMP ___ with presumed ectopic (never seen on ultrasound) presents to ED with severe abdominal pain after treatment with MTX on ___. She was having some mild abdominal pain responsive to Tylenol but this morning her pain became ___ and unresponsive to Tylenol. She describes the pain as located across her low abdomen, left > right. It was "unbearable" and she had trouble walking although wasn't lightheaded, just overwhelmed with pain. In the ambulance ride, she received 50mcg fentanyl and 4mg zofran IV. Her pain is now ___. She also notes vaginal bleeding, ~3 pads per day. No clots. ___ TVUS (prelim): Focal thickening of the endometrium, portion with vascular flow -> consistent with ongoing SAB. Cystic structure in left ovary most likely corpus luteum. <PAST MEDICAL HISTORY> PGynHx: Notes severe dysmenorrhea, normally takes Aleve. Previously on OCPs. PMHx: denies PSHx: denies <SOCIAL HISTORY> ___ <FAMILY HISTORY> NC <PHYSICAL EXAM> VS on arrival: 97.4 58 106/55 100% RA General: NAD Cardiac: RRR Pulm: CTA Abdomen: Soft, no focal tenderness with NO rebound or guarding. +BS Bimanual: Mildly enlarged AV uterus without tenderness or CMT. Some left adnexal fullness without discrete tenderness (pt notes diffuse "tenderness") Ext: NT, NE Labs: HCG 1845 CBC 7.8>41.7<221 Blood type O+ <PERTINENT RESULTS> ___ 11: 57AM BLOOD WBC-7.8# RBC-4.77 Hgb-13.3 Hct-41.7 MCV-88 MCH-27.9 MCHC-31.9 RDW-14.0 Plt ___ ___ 11: 57AM BLOOD ___ PTT-28.0 ___ ___ 11: 57AM BLOOD Glucose-87 UreaN-11 Creat-0.8 Na-136 K-4.4 Cl-105 HCO3-25 AnGap-10 ___ 11: 57AM BLOOD Mg-2.0 ___ 11: 57AM BLOOD HCG-1845 <MEDICATIONS ON ADMISSION> none <DISCHARGE MEDICATIONS> 1. Percocet 7.5-325 mg Tablet Sig: ___ Tablets PO every ___ hours. Disp: *30 Tablet(s)* Refills: *0* <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> PRESUMED ECTOPIC PREGNANCY <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 in the setting of suspected ectopic pregnancy. This was thought to be due to either ongoing miscarriage or aborting tubal ectopic. There was no evidence of a ruptured ectopic pregnancy. 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 ___ year old G1 with LMP at end of ___ and a presumed ectopic who presents with severe abdominal pain after methotrexate administration. On arrival in the ED, she was hemodynamically stable with a hematocrit of 41 and benign abdominal exam. Ultrasound showed a small amount of material in the lower uterine segment, no adenxal masses or free fluid. She was admitted for observation in the absence of any signs of ruptured ectopic. She did well overnight, only requiring tylenol for analgesia. She remained hemodynamically stable without change in abdominal exam. She was discharged to home on HD 2 in good condition.
| 838 | 143 |
10005001-DS-6
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___ <CHIEF COMPLAINT> Abdominal bloating <MAJOR SURGICAL OR INVASIVE PROCEDURE> Right salpingo-oophorectomy Left cystectomy <HISTORY OF PRESENT ILLNESS> Ms. ___ is a ___ gravida 0 woman who complains of abdominal bloating. She has a long gynecological history significant for uterine fibroids, endometriosis, and endometriomas. While she first started having symptoms of abdominal bloating, menorrhagia, severe menstrual cramping, urinary frequency, nocturia, and constipation in ___, her multiple gynecological diagnoses were not made until she received her first pelvic ultrasound in ___. After multiple myomectomies with Dr. ___ patient was followed biannually, then annually, and finally as needed for symptoms. In ___, ___ noticed abdominal bloating, which she described as a sensation of heaviness in her lower abdomen. A pelvic ultrasound in ___ showed an unchanged fibroid uterus, an unchanged 5.6cm left-sided endometrioma, and a new nodular 7.5cm right-sided endometrioma up to 5mm in wall thickness, concerning for malignant transformation. The patient presents today for surgical evaluation of her imaging findings. ROS was negative for F/C, CP, SOB, abdominal pain, N/V, C/D, changes in bowel or bladder habits, or intermenstrual bleeding. ROS was positive for mild dysmenorrhea, relieved by OTC NSAIDs. <PAST MEDICAL HISTORY> Past OB/GYN: The patient has regular menses. She has never had a pregnancy. Her last Pap smear was in ___, which was normal. She does have a history of genital warts. The patient has a long history of uterine fibroids, endometriosis, endometriomas. She is in a monogamous relationship with a female partner and uses a Mirena IUD. PMH: Allergic rhinitis Depression Uterine fibroids Endometriosis Endometriomas Pseudocholinesterase deficiency PSH: Medial collateral ligament release ___ Abdominal MMY <SOCIAL HISTORY> ___ <FAMILY HISTORY> Her mother had hypertension and died of colon cancer. Her father has hypertension and prostate cancer. <PHYSICAL EXAM> DISCHARGE EXAM: VS: Gen: This is a well-developed, well-nourished woman in no apparent distress. HEENT: Mucus membranes moist. Oropharynx clear. CV: Regular rate and rhythm. Normal S1 and S2 without murmurs, rubs, or gallops. Pulm: Clear to auscultation bilaterally Abd: Normoactive bowel sounds. Soft, nondistended, nontender. No hepatosplenomegaly. Well-healed ___ scar from her previous MMY. Incision intact. Pelvic: Normal female external genitalia. No rashes or lesions. Bartholin, urethral, and Skene's glands were normal. The vaginal vault contained normal-appearing vaginal discharge. The cervix was nulliparous, without cervical motion tenderness. Uterus was mobile and adnexa were difficult to appreciate given the patients habitus. Ext: 2+ peripheral pulses. No clubbing, cyanosis, or edema. Neuro: Awake, alert, and oriented to person, place, and time. Gross motor and sensory functions intact. <MEDICATIONS ON ADMISSION> Duloxetine 60mg PO QD Lorazapam 0.5mg PO QD as needed <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: *2* 2. oxycodone-acetaminophen ___ mg Tablet Sig: ___ Tablets PO Q4H (every 4 hours) as needed for pain. Disp: *40 Tablet(s)* Refills: *0* 3. duloxetine 30 mg Capsule, Delayed Release(E.C.) Sig: Two (2) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 4. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable Sig: One (1) Tablet, Chewable PO QID (4 times a day) as needed for dyspepsia. 5. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day as needed for constipation. Disp: *60 Capsule(s)* Refills: *2* <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> Primary diagnosis: Endometriomas Secondary diagnoses: Fibroid uterus, endometriosis <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> General instructions: * Take your medications as prescribed. * Do not drive while taking narcotics. * Do not combine narcotic and sedative medications or alcohol * Do not take more than 4000mg acetaminophen (APAP) in 24 hrs * No strenuous activity until your post-op appointment * Nothing in the vagina (no tampons, no douching, no sex), no heavy lifting of objects >10lbs for 6 weeks. * You may eat a regular diet Incision care: * You may shower and allow soapy water to run over incision; no scrubbing of incision. No bath tubs for 6 weeks. * If you have steri-strips, leave them on. They will fall off on their own or be removed during your followup visit. * If you have staples, they will be removed at your follow-up visit. To reach medical records to get the records from this hospitalization sent to your doctor at home, call ___.
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Ms. ___ is a ___ gravida 0 with a history of uterine fibroids, endometriosis, and endometriomas who complains of worsening abdominal bloating and was found to have a 7.5 cm right endometrioma concerning for malignancy. She was taken to the OR for right salpingo-oophorectomy and left cystectomy with possible total abdominal hysterectomy and cancer staging. Intraoperatively, she was found to have an unchanged fibroid uterus, evidence of endometriosis, and bilateral endometriomas. A right salpingo-oophorectomy and left cystectomy were performed. Frozen pathology sections were found to contain only benign columnar epithelium, and therefore the patient was closed. Cystoscopy showed bilateral ureteral jets of indigo ___ dye, suggestive of intact ureters at the end of the procedure. Please refer to the operative note for full details. Postoperatively, the patient did well, tolerating a regular diet and oral pain medications by POD1. On POD1, her Foley catheter was removed. She was discharged to home in good condition on post-operative day 2.
| 1,302 | 244 |
10005001-DS-7
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___ <CHIEF COMPLAINT> symptomatic fibroid uterus, left ovarian cyst <MAJOR SURGICAL OR INVASIVE PROCEDURE> exploratory laparotomy, lysis of adhesions, multiple myomectomy, left ovarian cystectomy <HISTORY OF PRESENT ILLNESS> Ms. ___ is a ___ gravida 0 with a long history of recurrent ovarian cyst and endometriosis who on ___, underwent a right salpingo-oophorectomy, left ovarian cystectomy for endometriomas. In ___, she had a multiple myomectomies for symptomatic fibroid uterus. The patient presents today for followup of unknown left adnexal cyst. The patient notes that she has no abdominal pain. She is simply experiencing increased bloatedness and pelvic pressure. New symptoms, she has developed stress urinary incontinence with sneezing. We discussed that this certainly can be related to this large adnexal cyst in addition to her overweightedness. On ___, she had an ultrasound, which showed an anteverted uterus that measured 14.3 x 6.7 x 9.2 cm, slightly smaller than previous measurement on ___, where it measured 15.2 x 7.4 x 10.4 cm. Multiple masses were consistent with uterine fibroids. The dominant fibroid was seen at the fundus and measured 3.3 x 3.3 x 3.5 cm. The endometrium was distorted due to fibroids and not well evaluated. An IUD was demonstrated within the endometrial cavity. The patient is status post right oophorectomy, previously seen 10.7 cm left adnexal cyst again visualized and now measuring slightly larger at 10.8 x 10 cm. It predominantly was thin walled; however, there was one area with the appearance of an incomplete septation. This either represented a hydrosalpinx or peritoneal inclusion cyst, less likely a cystadenoma. There was no free pelvic fluid. These findings were discussed with the patient. <PAST MEDICAL HISTORY> Past OB/GYN: The patient has regular menses. She has never had a pregnancy. She does have a history of genital warts. The patient has a long history of uterine fibroids, endometriosis, endometriomas. She is in a monogamous relationship with a female partner. PMH: ___ rhinitis Depression Uterine fibroids Endometriosis Endometriomas Pseudocholinesterase deficiency PSH: Medial collateral ligament release ___ Abdominal MMY <SOCIAL HISTORY> ___ <FAMILY HISTORY> Her mother had hypertension and died of colon cancer. Her father has hypertension and prostate cancer. <PHYSICAL EXAM> Discharge <PHYSICAL EXAM> AVSS Gen NAD CV RRR P CTAB Abd soft, nondistended, appropriately tender to palpation, incision c/d/I Ext WWP <PERTINENT RESULTS> ___ 07: 25AM WBC-5.9 RBC-4.30 HGB-13.4 HCT-40.5 MCV-94 MCH-31.2 MCHC-33.1 RDW-11.9 RDWSD-41.6 ___ 07: 25AM PLT COUNT-268 <MEDICATIONS ON ADMISSION> Duloxetine 60mg QD <DISCHARGE MEDICATIONS> 1. DULoxetine 60 mg PO DAILY 2. Ibuprofen 600 mg PO Q6H: PRN pain RX *ibuprofen 600 mg 1 tablet(s) by mouth every six (6) hours Disp #*50 Tablet Refills: *0 3. OxyCODONE (Immediate Release) ___ mg PO Q4H: PRN severe pain RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours Disp #*40 Tablet Refills: *0 4. 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 <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> fibroid uterus, ovarian cyst <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Dear Ms. ___, You were admitted to the gynecology service after your procedure. You have recovered well and the team believes you are ready to be discharged home. Please call Dr. ___ office with any questions or concerns. Please follow the instructions below. General instructions: * Take your medications as prescribed. * Do not drive while taking narcotics. * Take a stool softener such as colace while taking narcotics to prevent constipation. * Do not combine narcotic and sedative medications or alcohol. * Do not take more than 4000mg acetaminophen (APAP) in 24 hrs. * No strenuous activity until your post-op appointment. * No heavy lifting of objects >10 lbs for 6 weeks. * You may eat a regular diet. * You may walk up and down stairs. Incision care: * You may shower and allow soapy water to run over incision; no scrubbing of incision. No tub baths for 6 weeks. * If you have steri-strips, leave them on. They will fall off on their own or be removed during your followup visit. * 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 an exploratory laparotomy, lysis of adhesions, left ovarian cystectomy, abdominal myomectomy for symptomatic fibroid uterus and left ovarian cyst. Please see the operative report for full details. Her post-operative course was uncomplicated. Immediately post-op, her pain was controlled with IV dilaudid and toradol. On post-operative day 1, her urine output was adequate so her foley was removed and she voided spontaneously. Her diet was advanced without difficulty and she was transitioned to PO oxycodone, Tylenol and ibuprofen (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.
| 1,324 | 183 |
10005001-DS-8
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> Malignant transformation of endometriosis - final pathology report pending. <MAJOR SURGICAL OR INVASIVE PROCEDURE> exploratory laparotomy, total abdominal hysterectomy, left salingo-oophrectomy, omentectomy, para-aortic lymph node biopsy, liver resection, cystoscopy <HISTORY OF PRESENT ILLNESS> Ms. ___ is a ___ G0 with a history of fibroids and endometriosis who presents today for consultation regarding a large left adnexal mass identified on imaging. In ___ she underwent an abdominal myomectomy with left ovarian cystectomy for 27 fibroids and a 15-cm endometrioma. She reports recovering well until around ___, when she started to experience epigastric discomfort and occasional shortness of breath. She underwent CTA of the chest to evaluate for PE, which was negative and there was no lymphadenopathy or suspicious nodule seen. In ___, she got the heaviest period she has had since her Mirena IUD was placed. She underwent endometrial biopsy on ___, which showed chronic endometritis. She was already taking doxycycline for a positive Lyme titer while awaiting confirmatory testing, but continued to have vaginal bleeding. Her followup Lyme testing was negative. She continued to feel quite fatigued and noted abdominal pain epigastrically as well as in the LLQ, back pain, and decreased appetite and constipation which got progressively more bothersome during ___. She ultimately went to the ED on ___ where she underwent CT scan of the abdomen and pelvis, which showed a large 10-cm left complex adnexal cystic mass with septations and irregular solid components. Additionally, there were multiple subcapsular hepatic lesions and peritoneal implants, as well as retroperitoneal lymphadenopathy. Findings were concerning for a metastatic primary ovarian neoplasm, such as cystadenocarcinoma, versus atypical distribution of endometriotic implants. On ___ patient underwent an MRI of the abdomen and pelvis lower thorax showed clear lung bases no focal consolidations no pleural or pericardial effusion. Liver showed multiple nonenhancing cystic subcapsular implants likely representing hemorrhage. The largest right arises from the right lobe of the liver and measured 4.1 x 2.8 cm. There was no associated enhancement likely represent adherent clot. There were no suspicious enhancing lesions intrinsic to the hepatic parenchyma. Again, in regard to the pelvis, there was a large cystic multiloculated left adnexal structure measuring up to 10.8 x 10.1 cm. The septations were thin without significant enhancement or nodular components. The loculations demonstrated fluid-filled areas correction fluid-filled levels also likely representing hemorrhage. Within one of the loculations, there was a dark spot sign a finding that could be consistent with endometriosis. A smaller right adnexal cystic structure was seen measuring 3.5 x 3.0 cm. Uterus was enlarged with multiple small fibroids and IUD was seen within the endometrial cavity at. There was a trace free fluid within the pelvis multiple cystic anterior peritoneal implants were visualized with fluid-filled levels likely representing hemorrhage. There was peripheral enhancement, which may be reactive in nature. One of these peritoneal implants appeared to have significant surrounding fat stranding. A left periaortic retroperitoneal lesion had a similar appearance. Multiple subcentimeter periaortic lymph nodes were nonspecific. There was no inguinal or pelvic lymphadenopathy. She saw Dr. ___ in the office on ___ and received a 1-month dose of Lupron. She was referred to ___ Oncology for further evaluation given atypical imaging findings. Of note, she had a CA125 checked on ___, which was 108, decreased from 209 in ___. CEA was 0.9 on ___. Today she reports abdominal bloating, constipation, decreased appetite and increased abdominal girth. She noted decreased vaginal spotting since her Lupron shot, but it has been persistent. She also reports continued fatigue and occasional nausea. She denies chest pain, shortness of breath, diarrhea or dysuria. <PAST MEDICAL HISTORY> GYN HX: G0 - LMP ___, only minor spotting while IUD in place except when bleeding began in ___ - Currently sexually active with female partner - ___ history of abnormal Pap smears; last Pap ___ - Denies history of pelvic infections or sexually transmitted infections - Known history of fibroids and ovarian cysts - Known endometriosis PMH: - allergic rhinitis - depression - pseudocholinesterase deficiency - Denies hypertension, diabetes, asthma, thromboembolic disease PSH: - ___ knee surgery - ___ abdominal myomectomy - ___ RSO, L ov cystectomy -> Path: endometriotic cyst with focal metaplastic/reactive changes - ___ abdominal myomectomy, LOA, L ovarian cystectomy -> Path: leiomyomata with degenerative changes, endometriotic cyst <SOCIAL HISTORY> ___ <FAMILY HISTORY> FHx: - Father living, hx of bladder, prostate, skin, and throat cancer (non-smoker) - Mother died age ___ of colon cancer, also had DM and glaucoma - Brother is healthy - Niece with cystic fibrosis - No known family history of breast, uterine, ovarian, or cervical <PHYSICAL EXAM> On day of discharge: Afebrile, vitals stable No acute distress CV: regular rate and rhythm Pulm: clear to auscultation bilaterally Abd: soft, appropriately tender, nondistended, incision clean/dry/intact, no rebound/guarding ___: nontender, nonedematous <MEDICATIONS ON ADMISSION> duloxetine 60mg daily <DISCHARGE MEDICATIONS> 1. Acetaminophen 1000 mg PO Q6H: PRN Pain - Mild do not exceed 4000mg in 24 hours RX *acetaminophen 500 mg 2 tablet(s) by mouth every 6 hours Disp #*60 Tablet Refills: *2 2. Docusate Sodium 100 mg PO BID RX *docusate sodium 100 mg 1 capsule(s) by mouth twice daily Disp #*60 Capsule Refills: *2 3. Enoxaparin Sodium 30 mg SC Q12H Start: ___, First Dose: Next Routine Administration Time Take this medication for a total of 28 days after your surgery, ending ___. RX *enoxaparin 30 mg/0.3 mL 30 mg SC twice a day Disp #*50 Syringe Refills: *0 4. Ferrous GLUCONATE 324 mg PO DAILY RX *ferrous gluconate 324 mg (36 mg iron) 1 tablet(s) by mouth daily Disp #*30 Tablet Refills: *2 5. Ibuprofen 600 mg PO Q6H: PRN Pain - Moderate take with food RX *ibuprofen 600 mg 1 tablet(s) by mouth every 6 hours Disp #*60 Tablet Refills: *1 6. OxyCODONE (Immediate Release) ___ mg PO Q4H: PRN Pain - Severe do not drive or drink alcohol, causes sedation RX *oxycodone 5 mg ___ tablet(s) by mouth every 4 hours Disp #*50 Tablet Refills: *0 7. DULoxetine 60 mg PO DAILY <DISCHARGE DISPOSITION> Home With Service Facility: ___ <DISCHARGE DIAGNOSIS> malignant transformation of endometriosis <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Dear Ms. ___, . You were admitted to the gynecologic oncology service after undergoing the procedures listed below. You have recovered well after your operation, and the team feels that you are safe to be discharged home. Please follow these instructions: . Abdominal instructions: * Take your medications as prescribed. We recommend you take non-narcotics (i.e. Tylenol, ibuprofen) regularly for the first few days post-operatively, and use the narcotic as needed. As you start to feel better and need less medication, you should decrease/stop the narcotic first. * Do not drive while taking narcotics. * Do not combine narcotic and sedative medications or alcohol. * Do not take more than 4000mg acetaminophen (tylenol) in 24 hrs. * No strenuous activity until your post-op appointment. * Nothing in the vagina (no tampons, no douching, no sex) for 12 weeks. * No heavy lifting of objects >10 lbs for 6 weeks. * You may eat a regular diet. * It is safe to walk up stairs. . Incision care: * You may shower and allow soapy water to run over incision; no scrubbing of incision. No bath tubs for 6 weeks. * If you have staples, they will be removed at your follow-up visit. . To reach medical records to get the records from this hospitalization sent to your doctor at home, call ___. . Call your doctor at ___ for: * fever > 100.4 * severe abdominal pain * difficulty urinating * vaginal bleeding requiring >1 pad/hr * abnormal vaginal discharge * redness or drainage from incision * nausea/vomiting where you are unable to keep down fluids/food or your medication * chest pain or difficulty breathing * onset of any concerning symptoms
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Ms. ___ was admitted to the gynecologic oncology service after undergoing exploratory laparaotomy, total abdominal hysterectomy, left salpingo-oophorectomy, omentectomy, para-aortic lymph node biopsy, liver resection and cystoscopy for malignant transformation of endometriosis. 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 and Dilaudid PCA with toradol. Her diet was gradually advanced without difficulty and she was transitioned to oral oxycodone, Tylenol and ibuprofen. On post-operative day #2, her urine output was adequate so her Foley catheter was removed and she voided spontaneously. By post-operative day 5, she was tolerating a regular diet, voiding spontaneously, ambulating independently, and pain was controlled with oral medications. She was then discharged home in stable condition with outpatient follow-up scheduled.
| 2,096 | 201 |
10005812-DS-10
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Patient recorded as having No Known Allergies to Drugs <ATTENDING> ___. <CHIEF COMPLAINT> Premature Preterm Rupture of Membranes <MAJOR SURGICAL OR INVASIVE PROCEDURE> D+E <HISTORY OF PRESENT ILLNESS> ___ G3P1 at ___ presented to the ED with leaking of fluid and N/V x 1d. N/V started last night after eating at ___, had emesis x 1, sudden onset. Woke this morning with persistent nausea, emesis x 1 today. Had "gush of fluid" after emesis last night with persistent leaking of clear fluid throughout the day; she has needed to wear a pad. Mild lower abd cramping also started today. Denies F/C, cough, dysuria, changes in bowel habits, sick contacts, vaginal bleeding. Continues to feel flutters of FM. U/S in ED demonstrated cervical funneling with an open internal os. An MRI also confirmed this, with no evidence of appendicitis. <PAST MEDICAL HISTORY> PNC: - ___: ___ - labs: unknown - screening: per pt, FFS wnl POBHX: G3 ___ - LTCS x 1, term, ___ arrest of dilation 5cm - SAB x 1 PGYNHX: - menstrual cycle: regular - Paps: denies hx abnl; no hx cervical procedures - STIs: denies PMH: - pseudotumor cerebri PSH: - LTCS - ACL reconstruction <SOCIAL HISTORY> ___ <FAMILY HISTORY> NC <PHYSICAL EXAM> VS: 98.4 110 127/74 16 100RA GENERAL: NAD CARDIO: RRR PULM: CTAB ABDOMEN: soft, very mild TTP b/l LQ R>L, no R/G, mildly gravid EXTREMITIES: NT b/l SSE: +pooling, +nitrazine with membranes seen at os, which appears 2-3cm dilated bedside TAUS: adeq fluid, +FM, FHR 168bpm (M-mode) <PERTINENT RESULTS> ___ 09: 50PM WBC-25.4* RBC-4.02* HGB-12.2 HCT-35.2* MCV-88 MCH-30.4 MCHC-34.6 RDW-14.1 ___ 09: 50PM PLT COUNT-304 ___ 09: 50PM NEUTS-84.0* LYMPHS-12.0* MONOS-3.3 EOS-0.4 BASOS-0.3 ___ 09: 50PM ALT(SGPT)-21 AST(SGOT)-17 ALK PHOS-99 TOT BILI-0.4 ___ 09: 50PM LIPASE-17 ___ 09: 50PM GLUCOSE-110* UREA N-5* CREAT-0.6 SODIUM-137 POTASSIUM-3.8 CHLORIDE-104 TOTAL CO2-20* ANION GAP-17 ___ 10: 31PM ___ PTT-28.4 ___ ___ 10: 31PM ___ ___ 09: 40PM URINE COLOR-Straw APPEAR-Clear SP ___ ___ 09: 40PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 LEUK-SM ___ 09: 40PM URINE ___ BACTERIA-RARE YEAST-NONE EPI-0 ___ 05: 52AM WBC-24.8* RBC-3.77* HGB-11.8* HCT-34.0* MCV-90 MCH-31.3 MCHC-34.8 RDW-13.1 ___ 05: 52AM PLT COUNT-283 ___ 05: 52AM ___ PTT-25.4 ___ ___ 05: 52AM ___ URINE CULTURE (Final ___: MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION. ___ 5: 55 am SWAB Fluid should not be sent in swab transport media. Submit fluids in a capped syringe (no needle), red top tube, or sterile cup. SWAB OF VAGINAL -AMNIOTIC FLUID. **FINAL REPORT ___ GRAM STAIN (Final ___: 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. 3+ ___ per 1000X FIELD): GRAM NEGATIVE ROD(S). 2+ ___ per 1000X FIELD): GRAM POSITIVE ROD(S). FLUID CULTURE (Final ___: Due to mixed bacterial types (>=3) an abbreviated workup is performed; P.aeruginosa, S.aureus and beta strep. are reported if present. Susceptibility will be performed on P.aeruginosa and S.aureus if sparse growth or greater.. HAEMOPHILUS SP. SPARSE GROWTH. <MEDICATIONS ON ADMISSION> PNV <DISCHARGE MEDICATIONS> 1. Motrin 600 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for pain. Disp: *60 Tablet(s)* Refills: *0* 2. Percocet ___ mg Tablet Sig: ___ Tablets PO every ___ hours as needed for pain. Disp: *20 Tablet(s)* Refills: *0* 3. Doxycycline Monohydrate 100 mg Tablet Sig: One (1) Tablet PO twice a day for 7 days. Disp: *14 Tablet(s)* Refills: *0* <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> s/p D+E for pprom at 20 wks <DISCHARGE CONDITION> stable <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Pelvic rest for 6 weeks
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Mrs. ___ was transferred from the ED to L+D, where she was initially expectantly managed for her PPROM. She was started on ampicillin, gentamicin, and clindamycin. However, it became apparent that she had developed chorioamnionitis (foul-smelling green-tinged amniotic fluid as well as fundal tenderness and an elevated white count). She was counseled regarding the prognosis and the significant risks to herself, and she agreed to undergo dilatation and evacuation of the fetus. Dr. ___ this procedure on ___. It was uncomplicated; op-note available in OMR. The patient was transferred to the Gynecology service post-operatively where she was continued on triple antibiotic therapy. She did well on this and remained afebrile on post-op day #1, when she was discharged home on oral doxycycline. She saw social work as well during her stay.
| 1,350 | 197 |
10006196-DS-11
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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> ___ G1P0 at 25w0d with known posterior previa who presents with first episode of spotting in this pregnancy. No ctx, LOF. +FM. <PAST MEDICAL HISTORY> ___ ___ tri us Labs Rh+/Abs-/RI/RPRNR/HBsAg-/HIV-/GBS unknown Genetics LR ERA FFS normal, complete posterior previa GLT not yet done Issues 1. post previa on FFS OBHx: G1 GynHx: hx LGSIL ___, no f/u. PMH: denies PSH: denies <SOCIAL HISTORY> ___ <FAMILY HISTORY> non-contributory <PHYSICAL EXAM> (on admission) VITALS: T 98.6, HR 108, BP 113/71 GENERAL: A&O, comfortable ABDOMEN: soft, gravid, nontender GU: no bleeding on pad EXT: no calf tenderness TOCO no ctx FHT 150/mod var/+accels/-decels On discharge: afebrile, VSS Gen: NAD Abd: soft, nontender, gravid ___: without edema <PERTINENT RESULTS> n/a <MEDICATIONS ON ADMISSION> prenatal vitamins <DISCHARGE MEDICATIONS> 1. Prenatal Vitamins 1 TAB PO DAILY 2. Ranitidine 150 mg PO BID: PRN heartburn <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> posterior placenta previa, spotting <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 after having some spotting, which has since resolved. You received a complete course of steroids and had reassuring monitoring during your stay. You had an ultrasound done which showed a persistent placenta previa covering the cervix. Your doctors feel ___ are safe to go home with outpatient followup. Please call your doctor right away if you notice any additional vaginal bleeding or start having contractions. Your zantac prescription has been sent to the ___ on ___ ___.
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___ y/o G1P0 with posterior previa diagnosed at 20 weeks admitted to the antepartum service at 25w0d with small spotting. On admission, she was hemodynamically stable with no further bleeding. Speculum exam was deferred given her spotting had resolved. Fetal testing was reassuring. She was admitted to the antepartum service for observation. She had an ultrasound in the CMFM which revealed persistent complete previa. She was given two doses of betamethasone and had no active bleeding so she was discharged home in good condition on hospital day 2 with bleeding precautions and outpatient followup.
| 546 | 131 |
10010362-DS-11
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___ <CHIEF COMPLAINT> "s/p cesarean section complicated by PPH requiring transfusion" <MAJOR SURGICAL OR INVASIVE PROCEDURE> cesarean section <HISTORY OF PRESENT ILLNESS> The patient is a ___ gravida 2, para 0, who presented in early labor on ___ after spontaneous rupture of membranes. She progressed to 8 cm at around 10 a.m. on ___ with expectant management, but cervical dilitation did not progress. The patient agreed to augment her labor with Pitocin. However, she did continue to labor without neuraxial anesthesia. The Pitocin was titrated per protocol, but she did not make any cervical change for several hours. At this point an intrauterine pressure catheter was recommended; the patient declined. She did elect for a combined spinal epidural and afterwards the Pitocin was continued to be titrated per protocol. However, after 12 hours, she was still found to be 8 cm, 100%, and -1 station. Therefore, the recommendation was made to proceed with a primary cesarean section due to arrest. The risks and benefits were discussed with the patient and her partner, all questions were answered, all consents were signed. She had a reassuring fetal status prior to surgery. Total EBL was 800cc. She was transferred to the postpartum floor and then experienced several gushed of bright red blood mixed with clots from her vagina. She was brought back to the Labor floor. <SOCIAL HISTORY> ___ <FAMILY HISTORY> Non-contributory <PHYSICAL EXAM> On examination during PPH, pt had bled out 400cc of blood clots in the bed. U/S showed some lower uterine segment clots. Endometrial stripe appeared adequate. Evacuated 400cc more of blood from lower uterine segment. She received 1000mcg of cytotec and 40 units of pitocin. Pt was transferred back to labor and delivery for continued bleeding. <PERTINENT RESULTS> ___ 12: 15AM BLOOD WBC-15.5* RBC-4.59 Hgb-14.1 Hct-39.4 MCV-86 MCH-30.7 MCHC-35.7* RDW-13.4 Plt ___ ___ 12: 41AM BLOOD WBC-20.4* RBC-3.91* Hgb-12.3 Hct-33.8* MCV-87 MCH-31.4 MCHC-36.4* RDW-13.6 Plt ___ ___ 03: 27AM BLOOD WBC-22.4* RBC-3.50* Hgb-10.9* Hct-30.3* MCV-87 MCH-31.2 MCHC-36.0* RDW-13.7 Plt ___ ___ 07: 31AM BLOOD WBC-15.9* RBC-2.71* Hgb-8.2* Hct-23.2* MCV-86 MCH-30.1 MCHC-35.2* RDW-13.8 Plt ___ ___ 05: 06PM BLOOD WBC-15.1* RBC-3.05* Hgb-9.7* Hct-26.9* MCV-88 MCH-31.7 MCHC-36.0* RDW-14.1 Plt ___ ___ 08: 35AM BLOOD WBC-16.6* RBC-2.90* Hgb-9.0* Hct-25.6* MCV-88 MCH-30.9 MCHC-35.0 RDW-14.2 Plt ___ <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 for Constipation. Disp: *60 Capsule(s)* Refills: *1* 2. oxycodone-acetaminophen ___ mg Tablet Sig: ___ Tablets PO Q3H (every 3 hours) as needed for Pain. Disp: *45 Tablet(s)* Refills: *0* 3. ibuprofen 600 mg Tablet Sig: ___ Tablets PO Q6H (every 6 hours) as needed for Pain. Disp: *60 Tablet(s)* Refills: *1* 4. ferrous sulfate 325 mg (65 mg iron) Capsule, Extended Release Sig: One (1) Capsule, Extended Release PO twice a day. Disp: *60 Capsule, Extended Release(s)* Refills: *2* <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> s/p cesarean section 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> routine postpartum
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Ms. ___ was transferred back to labor and delivery when her bleeding failed to stop with 40 units of pitocin, 1000mcg of cytotec and manual evacuation. Her bleeding however did resolve after she received 0.2mg of IM Methergine. Her HCT was trended and found to nadir at 23.2. She had tachycardia and a low urine output. The decision was the made to transfuse her for symptomatic anemia. She received 2 units of red cells and her hematocrit responded appropriately to 25.6, her urine output and heart rate improved significantly. The rest of her postpartum course was uncomplicated.
| 1,138 | 145 |
10010374-DS-17
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> abdominal pain <MAJOR SURGICAL OR INVASIVE PROCEDURE> none <HISTORY OF PRESENT ILLNESS> ___ year-old Gravida 2 Para 1 at 28 weeks 6 days gestational age who presented with acute onset left lower quadrant pain while laying still in bed. She got up and urinated and it gradually worsened to ___. She had never experienced this kind of pain before. It was twisting and very sharp in nature and constant. Worse with legs extended vs flexed. A couple of hours after the pain started, she started to feel uterine tightening. Denied fever, chills, nausea, vomiting, diarrhea, dysuria, vaginal bleeding, leaking of fluid, hematuria, abnormal vaginal discharge. + Fetal movement. Last intercourse the morning prior. <PAST MEDICAL HISTORY> PRENATAL COURSE - Estimated Due Date: ___ - labs: A+/Ab- - screening: GLT wnl, FFS wnl . OBSTETRIC HISTORY Gravida 2 Para 1 (___) @ ___: Vacuum-assisted vaginal delivery @ 34 ___ wks, spontaneous preterm labor, had been hospitalized during pregnancy @ 30 weeks with vaginal bleeding and received betamethasone. 5#4, male GYNECOLOGIC HISTORY: remote history of chlamydia . PAST MED/SURG HISTORY: benign <SOCIAL HISTORY> ___ <FAMILY HISTORY> non-contributory <PHYSICAL EXAM> (on admission) VS: T 98.3, RR 18, BP 97/66, HR 130->115 GENERAL: crying, lying on her side in fetal position, very uncomfortable, able to speak in full sentences CARDIO: reg rhythm, tachy PULM: CTAB BACK: no CVA tenderness ABDOMEN: soft, gravid, most TTP LLQ just superior to inguinal area (no palpable underlying masses) though tender more superiorly as well, no R/G, no uterine TTP EXTREMITIES: NT b/l SSE: def SVE/BME: L/C/P TOCO: no clear ctx FHT: 150, mod var, AGA, no decels BPP: ___, cephalic, DVP 5.3, EFW 1328g 2#15oz <PERTINENT RESULTS> ___ WBC-9.0 RBC-3.95 Hgb-12.8 Hct-36.4 MCV-92 Plt-404 ___ Neuts-72.8 ___ Monos-6.3 Eos-1.4 Baso-0.4 ___ WBC-9.5 RBC-4.04 Hgb-12.3 Hct-36.4 MCV-90 Plt-417 ___ Neuts-70.0 ___ Monos-5.6 Eos-1.1 Baso-0.4 . ___ ___ PTT-31.1 ___ ___ . ___ Glucose-73 BUN-4 Creat-0.5 Na-134 K-4.2 Cl-102 HCO3-22 ___ Calcium-8.7 Phos-3.7 Mg-2.0 . ___ URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-SM . Pelvic Ultrasound: Limited views demonstrate a live single intrauterine gestation with normal cardiac activity. The cervix remains long and closed. Please note that this limited exam does not substitute a full fetal survey. . Attention was then directed to bilateral superiorly displaced ovaries, necessitating use of linear probe. The left ovary measures 2.7 x 2 x 1.5 cm, with normal arterial and venous flow. The right ovary measures 2.2 x 1.4 x 1 cm, with normal venous flow. Arterial flow on the right is not demonstrated. The ovaries appear normal in size and morphology. There is no focal tenderness over the superiorly displaced ovaries. . Targeted ultrasound was performed to the site of symptomology in the lower abdomen, away from the ovaries, demonstrating no focal pathology. . IMPRESSION: 1. Normal size and morphology of bilateral ovaries. Normal vascularity of the left ovary. Limited arterial assessment of the right ovary. 2. Limited exam of single intrauterine gestation with normal cardiac activity and closed cervix. For full assessment of the fetus, continued routine fetal followup is recommended. 3. Tenderness in the lower abdomen is away from superiorly displaced ovaries. No discrete pathology is demonstrated at the site of symptom. <MEDICATIONS ON ADMISSION> prenatal vitamin folic acid <DISCHARGE MEDICATIONS> prenatal vitamin folic acid <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> pregnancy at 29+0 weeks gestation suspected viral gastroenteritis <DISCHARGE CONDITION> stable <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> stay well hydrated
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Ms. ___ received 0.5mg of IV Dilaudid in triage and her pain greatly improved. As above, her pelvic ultrasound was negative for any pathology and her laboratory studies were unrevealing. She did not require any additional analgesics and was admitted to the antepartum floor for close observation and abdominal exams. While there, she had an episode of emesis after eating and began having chills and feeling generally unwell with no abdominal pain, but abdominal discomfort. She remained afebrile with no elevation of white count and had no other focal signs or symptoms. It was thought that she had a mild viral gastritis. Her left lower quadrant pain never returned. She was given zantac, oral zofran and IV hydration and by the afternoon on hospital day #2 was feeling better. . Fetal testing was reassuring by ultrasound and non-stress testing. She had no signs of labor and her cervix remained closed. . She was discharged home on hospital day #2 symptomatically improved.
| 1,130 | 210 |
10014107-DS-6
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> cramping <MAJOR SURGICAL OR INVASIVE PROCEDURE> vaginal delivery <HISTORY OF PRESENT ILLNESS> ___ y/o G5P0040 GDMA, ___ ___ presents to triage with the complaint of cramping and lower back pain. she states the cramping began yesterday and decided that if still cramping would call in the morning. she denies vaginal spotting or leaking. Active fetal movements. <PAST MEDICAL HISTORY> PNC *) Dating ___ ___ by LMP consistant w/7+4 wk u/s *) Labs: AB pos/Ab neg/R-I/RPR-NR/HBsAg neg/HIV negHCV neg *) FFS unremarkable, placenta anterior no previa, cl 44mm *) glucola: ___ ___ ___ issues short CL,on vaginal progesterone, received BMZ and complete on ___. GDMA1 OBHx TAB x 2 SAB x 2 GYNHx LMP ___ LEEP denies STI's PMH benign <SOCIAL HISTORY> ___ <FAMILY HISTORY> noncontributory <PHYSICAL EXAM> O: BP 126/73 HR 92 RR 14 temp 98 RRR CTA B ABD gravid, soft, NT FHT 145 ___, AGA Toco ctx q ___ mins fFN obtain but not sent given a change in cx SVE 1.5cm/100/BBOW cephalic by U/S <MEDICATIONS ON ADMISSION> prenatal vitamins insulin <DISCHARGE MEDICATIONS> 1. 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 <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> preterm labor, insulin requiring gestational diabetes <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> pelvic rest
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Pt was initially found to be 1.5cm dilated. She was observed on the antepartum service and kept on bedrest. On the morning of ___, her cramping increased and became painful, she was found the be 7cm dilated and in active labor. She was transferred to L&D and had an uncomplicated vaginal delivery of a liveborn male, who was brought to NICU. She did well postpartum and was discharged home on PPD#2.
| 490 | 102 |
10014383-DS-10
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> adhesive / Venomil Yellow Jacket Venom / Codeine / Vicodin / lisinopril <ATTENDING> ___ <CHIEF COMPLAINT> cystocele, stress urinary incontinene <MAJOR SURGICAL OR INVASIVE PROCEDURE> anterior colporrhaphy, suburethral sling, cystoscopy <HISTORY OF PRESENT ILLNESS> The patient is a ___, referred for gynecologic evaluation regarding vaginal prolapse and stress incontinence. The patient was originally managed with a pessary, which she wore for approximately ___ years. She eventually experienced some vaginal spotting and elected for a more definitive management in the form of surgery. She was referred for multichannel urodynamic testing, which confirmed that she has stress urinary incontinence with urethral hypermobility. <PAST MEDICAL HISTORY> PMH: polymyalgia rheumatica, HTN, hypothyroidism, low back pain, SVD x4 PSH: TAH BSO, CCY, appx, carpal tunnel x2, temporal artery ligation <SOCIAL HISTORY> ___ <FAMILY HISTORY> Her family history is siginficant for a sister with ___ cancer and unremarkable for Ovarian or Colon cancer. <PHYSICAL EXAM> Preoperative physical exam: Vaginal exam : External genitalia: no lesions or discharge urethral meatus: no caruncle or prolapse urethra: non tender, no exudate Internal exam: There was moderate/severe vaginal atrophy. Vagina was inspected and there were ulcerations absent # 3 ring w/ support was removed and NOT REINSERTED Discharge exam: Gen: NAD CV: RRR Lungs: CTAB Abd: soft, NT, ND GU: minimal spotting on pad, clear urine in foley Ext: WWP, calves nontender <DISCHARGE INSTRUCTIONS> Dear Ms. ___, You were admitted to the gynecology service after undergoing an anterior repair and sling procedure. You have recovered well and are ready to be discharged. You are being discharged with a foley catheter in place. Please follow the instructions below: * Take your medications as prescribed. * Do not drive while taking narcotics. * Take a stool softener such as colace while taking narcotics to prevent constipation. * Do not combine narcotic and sedative medications or alcohol. * Do not take more than 4000mg acetaminophen (APAP) in 24 hrs. * No strenuous activity until your post-op appointment. * Nothing in the vagina (no tampons, no douching, no sex) for 6 weeks or until cleared at your post-operative 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. Call your doctor for: * fever > 100.4 * severe abdominal pain * difficulty urinating * vaginal bleeding requiring >1 pad/hr * abnormal vaginal discharge * redness or drainage from incision * nausea/vomiting where you are unable to keep down fluids/food or your medication To reach medical records to get the records from this hospitalization sent to your doctor at home, call ___. You were discharged home with a Foley (bladder) catheter and received teaching for it prior to discharge. You were also given a prescription for Macrodantin (nitrofurantoin) antibiotic to prevent a UTI while you have the catheter. Please take as prescribed. You should follow-up in Dr. ___ office in ___ on ___ at 9: 20am for catheter removal.
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Ms. ___ was admitted to the gynecology service after undergoing a TVT EXACT sling procedure, anterior colporrhaphy 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 and her Foley was removed with a voiding trial, the results of which are as follows: 1. Instilled 240 mL, voided 0 mL with 400 mL residual. 2. Instilled 300 mL, voided 0 mL with 350 mL residual. Her Foley catheter was replaced and she was instructed in its care. Her diet was advanced without difficulty and she was transitioned to oral pain medications. By post-operative day 1, she was tolerating a regular diet, ambulating independently, and pain was controlled with oral medications. She was then discharged home in stable condition with outpatient follow-up scheduled. Discharge Medications: 1. Levothyroxine Sodium 75 mcg PO DAILY 2. Losartan Potassium 50 mg PO DAILY 3. PredniSONE 5 mg PO DAILY 4. Docusate Sodium 100 mg PO BID RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day Disp #*30 Capsule Refills:*3 5. eszopiclone 3 mg oral HS 6. Hydrochlorothiazide 25 mg PO DAILY 7. Ibuprofen 600 mg PO Q8H:PRN Pain Take with food. RX *ibuprofen 600 mg 1 tablet(s) by mouth every eight (8) hours Disp #*50 Tablet Refills:*1 8. HYDROmorphone (Dilaudid) 2 mg PO Q4H:PRN pain Do not drive while taking this medication. RX *hydromorphone [Dilaudid] 2 mg 1 tablet(s) by mouth every four (4) hours Disp #*25 Tablet Refills:*0 9. Acetaminophen 1000 mg PO Q6H:PRN pain Do not exceed 4000 mg per day RX *acetaminophen 500 mg ___ tablet(s) by mouth every six (6) hours Disp #*30 Tablet Refills:*3 10. Nitrofurantoin (Macrodantin) 100 mg PO DAILY RX *nitrofurantoin macrocrystal 100 mg 1 capsule(s) by mouth once a day Disp #*5 Capsule Refills:*0 Discharge Disposition: Home Discharge Diagnosis: bladder prolapse stress urinary incontinence urinary retention Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___
| 816 | 612 |
10016832-DS-7
|
<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___ <CHIEF COMPLAINT> Headache <MAJOR SURGICAL OR INVASIVE PROCEDURE> cesarean delivery blood transfusions <HISTORY OF PRESENT ILLNESS> Pt presented with elevated BP, 144/98, and headache at 37w6d in the office. She went to L+D for evaluation. <PAST MEDICAL HISTORY> Her medical history is significant for: 1) hypertension 2) hyperlipidemia 3) seizure disorder secondary to AVM in the brain ___ with her first seizure ___ years ago and her last seizure ___ 4) history of migraine headaches 5) osteoarthritis of bilateral knee joints right greater than left 6) chronic low back pain 7) vitamin D deficiency 8) hepatic steatosis by ultrasound study Her surgical history includes: 1) right parietal-occipital AVM resection ___ 2) placement of a laparoscopic adjustable gastric band ___ 3) removal of adjustable gastric band secondary to prolapse ___ <SOCIAL HISTORY> ___ <FAMILY HISTORY> She works as a ___ at ___ and lives with her wife who is a ___. <PHYSICAL EXAM> On admission ___ 12: 41BP: 104/78 (85) ___ 12: 46BP: 131/81 (93) ___ 13: 01BP: 120/94 (97) ___ ___: 96 ___ 13: 16BP: 98/70 (75) ___ ___: 74 ___ 13: 21BP: 138/86 (97) ___ ___: 71 Gen: A&O, comfortable PULM: normal work of breathing Abd: soft, gravid, nontender EFW med-large, cephalic by ___ Ext: no calf tenderness On discharge: Vitals: 24 HR Data (last updated ___ @ 102) Temp: 97.9 (Tm 98.6), BP: 110/56 (109-126/56-76), HR: 65 (65-71), RR: 16 (___), O2 sat: 97% (95-98) Gen: NAD, A&Ox3 Cardiopulm: No respiratory distress Abd: soft, NTND, fundus firm, nontender, below umbilicus Incision: c/d/I, no erythema or purulent drainage Ext: no calf tenderness <PERTINENT RESULTS> ___ 06: 05AM BLOOD WBC-7.3 RBC-2.65* Hgb-8.2* Hct-25.0* MCV-94 MCH-30.9 MCHC-32.8 RDW-15.1 RDWSD-51.8* Plt ___ ___ 02: 01PM BLOOD WBC-7.5 RBC-2.65* Hgb-8.1* Hct-24.9* MCV-94 MCH-30.6 MCHC-32.5 RDW-15.3 RDWSD-52.2* Plt ___ ___ 06: 10AM BLOOD WBC-7.6 RBC-2.63* Hgb-8.1* Hct-24.5* MCV-93 MCH-30.8 MCHC-33.1 RDW-14.9 RDWSD-49.8* Plt ___ ___ 08: 20PM BLOOD WBC-8.7 RBC-2.21* Hgb-7.0* Hct-20.4* MCV-92 MCH-31.7 MCHC-34.3 RDW-14.9 RDWSD-50.2* Plt ___ ___ 06: 17AM BLOOD WBC-10.1* RBC-2.03* Hgb-6.3* Hct-19.1* MCV-94 MCH-31.0 MCHC-33.0 RDW-14.7 RDWSD-50.6* Plt ___ ___ 07: 52PM BLOOD WBC-14.8* RBC-2.51* Hgb-7.9* Hct-24.0* MCV-96 MCH-31.5 MCHC-32.9 RDW-14.3 RDWSD-49.9* Plt ___ ___ 12: 39PM BLOOD WBC-18.7* RBC-2.20* Hgb-7.0* Hct-21.9* MCV-100* MCH-31.8 MCHC-32.0 RDW-14.4 RDWSD-51.8* Plt ___ ___ 10: 30AM BLOOD WBC-15.6* RBC-2.40* Hgb-7.7* Hct-24.2* MCV-101* MCH-32.1* MCHC-31.8* RDW-14.2 RDWSD-51.6* Plt ___ ___ 12: 53PM BLOOD WBC-8.1 RBC-3.67* Hgb-11.7 Hct-34.6 MCV-94 MCH-31.9 MCHC-33.8 RDW-13.5 RDWSD-46.4* Plt ___ ___ 06: 10AM Creat-0.9 ___ 12: 39PM BLOOD Creat-1.2* ___ 12: 53PM BLOOD Creat-0.8 ___ 10: 30AM BLOOD ALT-10 AST-19 ___ 12: 53PM BLOOD ALT-15 AST-34 CXR (___) heart size is enlarged but this might represent physiologic pregnancy increased cardiovascular volume status, although true enlargement of the cardiac silhouette due to pathological causes is a possibility, correlation with echocardiography is recommended. Left retrocardiac opacity might represent atelectasis but infectious process is a possibility. No pulmonary edema. No appreciable pleural effusion. No pneumothorax. CT (___) Large anterior pelvic hematoma measures 15.0 x 9.9 x 9.2 cm. Moderate size hemoperitoneum. No active hemorrhage is identified. CTA (___) IMPRESSION: 1. Large lower anterior uterine segment bladder flap hematoma appears fairly similar in size to slightly contracted compared to prior imaging. No active extravasation of contrast/arterial bleed. 2. Small subcutaneous hematoma is in the lower anterior abdominal/pelvic wall. <MEDICATIONS ON ADMISSION> PNV, Lamictal ___ mg, folic acid, fioricet PRN, celexa 20mg <DISCHARGE MEDICATIONS> 1. Acetaminophen 1000 mg PO Q6H 2. Citalopram 15 mg PO DAILY 3. Ibuprofen 600 mg PO Q6H: PRN Pain - Mild RX *ibuprofen 600 mg 1 tablet(s) by mouth every six (6) hours Disp #*40 Tablet Refills: *0 4. OxyCODONE (Immediate Release) ___ mg PO Q4H: PRN pain RX *oxycodone 5 mg 1 tablet(s) by mouth every six (6) hours Disp #*20 Tablet Refills: *0 5. LamoTRIgine 600 mg PO QPM 6. LamoTRIgine 400 mg PO QAM <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> cesarean delivery preeclampsia post-operative bleeding anemia blood transfusions <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 ___ year old G1P1 who underwent a primary low transverse cesarean section on ___. Delivery by cesarean was chosen due to patient preference because of her history of epilepsy and prior surgery for arteriovenous malformation. Delivery was recommended as patient had developed a headache overnight refractory to medications. She was thus diagnosed with chronic HTN with superimposed severe pre-eclampsia, severe by HA. Her post operative course was complicated by acute blood loss anemia secondary to a large pelvic hematoma. Regarding her chronic hypertension with superimposed pre-eclampsia, her headache improved after delivery. She has normal labs and a urine p:c that was 0.26. She was started on magnesium post partum which was kept for 17 hours. Her magnesium was stopped early given new onset oliguria. A mag level was normal at ___. Regarding her acute blood loss anemia, patient initially started feeling symptomatics with BPs in the ___ on ___. She was noted to be oliguric at 30cc/hr and received a 250cc bolus. Given new shortness of breath, patient underwent a chest xray which returned consistent with atelectasis. Her hematocrit was trended and she was noted to have a significant decrease in her hematocrit from 34.6 pre-operatively to 21.9 on ___. Decision was made to transfuse 2 units of packed RBCs and obtain imaging. A CT abdomen and pelvis was notable for a 15.0 cm hematoma anterior to the lower uterine segment, moderate hemoperitoneum, and no evidence of active bleed. Given stability, ___ embolization deferred. On ___, patient required an additional 2 units of packed RBCs. She had an inappropriate rise in her hct at 20.4 from 19.1 and therefore was transfused another 2 units for a total of 6 units during her hospital stay. Given need for multiple blood transfusions, repeat imaging with CTA was obtained showing interval decrease in the hematoma and no area of active bleeding. Of note, given her acute blood loss anemia, patient suffered an ___, which resolved by ___. By ___, patient was in stable condition with stable vitals and stable labs. She met all her post operative milestones and was discharged to home with close follow up.
| 1,746 | 492 |
10017530-DS-5
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Insect Extracts <ATTENDING> ___ <CHIEF COMPLAINT> Post menopausal bleeding <MAJOR SURGICAL OR INVASIVE PROCEDURE> Total ___ hysterectomy, right salpingo-oophorectomy, omentectomy, and cystoscopy. <HISTORY OF PRESENT ILLNESS> ___ year-old gravida 0 who experienced postmenopausal bleeding that led to a pelvic ultrasound at ___ Ultrasound ___. This study dated revealed an endometrial polyp measuring 2.3 cm. This polyp had internal vascularity. The right ovary was well visualized and within it was a 1.8 cm complex cyst with multiple solid areas and areas of peripheral mural thickening and nodularity, some of which were vascularized. Notably, she has a history of bilateral borderline ovarian cancer and is status post a left salpingo-oophorectomy and right ovarian cystectomy in ___. <PAST MEDICAL HISTORY> OB/GYN History: She is a gravida 0. She reports that her last Pap smear was about a year ago and was normal. She has never had an abnormal Pap smear. She denies any history of pelvic infections or STDs. - History of bilateral borderline ovarian cancers. She underwent an exploratory laparotomy, left salpingo-oophorectomy, right ovarian cystectomy, partial omentectomy in ___. Postoperatively, she has had no evidence of disease recurrence and has been followed with annual visits. - Menopause a few years ago but has had some concerns with osteoporosis and therefore began bioidentical hormones under the care of Dr. ___. She has stopped using these since the bleeding that she had. . <PAST MEDICAL HISTORY> She reports a history of osteopenia. She denies any history of asthma, hypertension, cardiac disease, coronary artery disease, mitral valve prolapse, thromboembolic disorder, or cancer. She reports being up-to-date with mammograms, colonoscopies, and bone density evaluation. . Past Surgical History: As above. <SOCIAL HISTORY> ___ <FAMILY HISTORY> She reports a maternal first cousin had breast cancer. Both her mother and her father had colon cancer but at old ages. Her mother had the disease at the age of ___, and her father had the disease diagnosed just prior to his death in ___. <PHYSICAL EXAM> Performed by Dr. ___ on ___: GENERAL: Appears stated age, 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 CVA tenderness. ABDOMEN: Soft, nontender, nondistended. There is no mass. There is no hepato or splenomegaly. There is no fluid wave. 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 normal. Walls of the vagina are smooth. Apex is normal. Cervix is normal. Bimanual exam reveals a mobile uterus without mass or lesion. There is no cul-de-sac nodularity. <MEDICATIONS ON ADMISSION> None <DISCHARGE MEDICATIONS> 1. ibuprofen 600 mg Tablet Sig: One (1) Tablet PO every ___ hours as needed for pain. Disp: *60 Tablet(s)* Refills: *0* 2. oxycodone-acetaminophen ___ mg Tablet Sig: ___ Tablets PO every ___ hours as needed for pain: Do not drive while taking this medication. Disp: *60 Tablet(s)* Refills: *0* 3. docusate sodium 100 mg Capsule Sig: ___ Capsules PO BID (2 times a day) as needed for constipation: Take daily while taking narcotic to prevent constipation. Disp: *60 Capsule(s)* Refills: *0* <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> Borderline ovarian cancer <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Call your doctor for: * fever > 100.4 * severe abdominal pain * difficulty urinating * vaginal bleeding requiring >1 pad/hr * abnormal vaginal discharge * redness or drainage from incision * nausea/vomiting where you are unable to keep down fluids/food or your medication General instructions: * Take your medications as prescribed. * Do not drive while taking narcotics. * No strenuous activity, nothing in the vagina (no tampons, no douching, no sex), no heavy lifting of objects >10lbs for 6 weeks. * You may eat a regular diet. Incision care: * You may shower and allow soapy water to run over incision; no scrubbing of incision. No bath tubs for 6 weeks. * If you have steri-strips, leave them on. They will fall off on their own or be removed during your followup visit.
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Ms. ___ underwent a ___ right salpingo-oophorectomy, intraoperative pathology revealed borderline ovarian cancer and a total ___ hysterectomy, omentectomy, and cystoscopy was performed. She had a benign post-operative course and was discharged home on post-operative day #1 on oral pain medications, she was ambulating, tolerating a regular diet, and able to urinate without difficulty.
| 1,146 | 83 |
10019003-DS-15
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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> laparoscopic hysterectomy, bilateral salpingo-oophorectomy, cystoscopy <HISTORY OF PRESENT ILLNESS> Ms. ___ is a ___ G1, P1 who underwent an abdominal ultrasound to evaluate for abdominal aortic aneurysm given her strong history of tobacco use by her primary care physician. That ultrasound revealed a large pelvic mass. She then underwent a CT scan on ___ which revealed a large mass within the pelvis measuring 9.9 x 12.2 x 10.3 cm with internal locules corresponding to the area of nodularity identified in ultrasound. The mass was intensely associated with the left ovary and closely abuts the uterine fundus. While there is no clear fat plane seen between the mass and uterus, it is believed to be of ovarian in origin rather than uterine. There are scattered sigmoid diverticula. No free fluid in the pelvis. Bladder and rectum are unremarkable and there are no enlarged pelvic or inguinal lymph nodes. She states that she has been asymptomatic from this mass. Today, she has no complaints. She denies any vaginal bleeding, abdominal pain, nausea, vomiting, change in bladder or bowel habits. <PAST MEDICAL HISTORY> PAST MEDICAL HISTORY: Significant for breast cancer status post lumpectomy and adjuvant radiation, diabetes, hypertension, hypercholesterolemia, and depression. PAST SURGICAL HISTORY: Laparoscopic cholecystectomy and a right breast lumpectomy. OB AND GYN HISTORY: She is a gravida 1, para 1 with one spontaneous vaginal delivery. Her last menstrual period was when she was in her ___, menarche at age ___ with regular periods lasting four to five days. No history of abnormal Pap smears. Her last Pap was in ___, which was negative. No history of sexually transmitted infections, cysts or fibroids. <SOCIAL HISTORY> ___ <FAMILY HISTORY> She denies any family history of GYN malignancies. <PHYSICAL EXAM> Pre-operative exam: GENERAL: Well-appearing, no acute distress. CARDIOVASCULAR: Regular rate and rhythm, no murmurs. LUNGS: Clear to auscultation bilaterally. BACK: No CVA or spinal tenderness. ABDOMEN: Soft, nontender, nondistended. No masses appreciated. No hernias. EXTREMITIES: No edema. LYMPHATICS: No supraclavicular or inguinal lymphadenopathy. PELVIC: Normal external female genitalia. Speculum exam revealed paracervix. No lesions present. Bimanual exam revealed a normal-sized uterus. Mass was difficult to appreciate secondary to body habitus. Rectovaginal exam revealed no nodularity or masses appreciated. Normal rectal tone. Exam on discharge: GENERAL: Well-appearing, no acute distress. CARDIOVASCULAR: Regular rate and rhythm, no murmurs. LUNGS: Clear to auscultation bilaterally. BACK: No CVA or spinal tenderness. ABDOMEN: Soft, nontender, nondistended. Incision clean, dry, intact EXTREMITIES: No edema. Non tender <PERTINENT RESULTS> ___ 09: 22AM BLOOD WBC-10.3# RBC-3.50*# Hgb-11.3*# Hct-33.3*# MCV-95 MCH-32.3* MCHC-33.9 RDW-14.8 Plt ___ ___ 09: 22AM BLOOD Neuts-73.2* Lymphs-17.7* Monos-8.5 Eos-0.3 Baso-0.3 ___ 09: 22AM BLOOD Glucose-232* UreaN-14 Creat-1.1 Na-141 K-4.6 Cl-103 HCO3-30 AnGap-13 ___ 09: 22AM BLOOD Calcium-8.4 Phos-2.5* Mg-2.2 CTA (___): 1. Worsening emphysema. 2. No pulmonary embolus. 3. Bibasilar atelectasis at the lung bases. 4. 3-mm nodule in the right middle lobe. Consider followup in six months to document stability. 5. Hepatic steatosis. CXR (___): No acute intrathoracic process. <MEDICATIONS ON ADMISSION> ATENOLOL - (Prescribed by Other Provider) - 50 mg Tablet - 2 Tablet(s) by mouth daily GEMFIBROZIL - (Prescribed by Other Provider) - 600 mg Tablet - 1 Tablet(s) by mouth twice a day LISINOPRIL - 20 mg Tablet - 1 Tablet(s) by mouth day METFORMIN - (Prescribed by Other Provider) - 500 mg Tablet Extended Release 24 hr - 1 Tablet(s) by mouth evening PAROXETINE HCL - (Prescribed by Other Provider) - 40 mg Tablet - 1 Tablet(s) by mouth morning ROSUVASTATIN [CRESTOR] - (Prescribed by Other Provider) - 40 mg Tablet - 1 Tablet(s) by mouth evening Medications - OTC CALCIUM CARBONATE-VITAMIN D3 [CALCIUM 500 + D] - (Prescribed by Other Provider; ___) - Dosage uncertain CHOLECALCIFEROL (VITAMIN D3) [VITAMIN D] - (OTC) - Dosage uncertain MULTIVITAMIN - (OTC) - Tablet - 1 Tablet(s) by mouth morning OMEGA-3 FATTY ACIDS-VITAMIN E [FISH OIL] - (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: *50 Tablet(s)* Refills: *0* 2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation. Disp: *60 Capsule(s)* Refills: *0* 3. paroxetine HCl 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Tablet(s) 4. atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. Disp: *60 Tablet(s)* Refills: *0* 7. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: One (1) puff Inhalation three times a day as needed for shortness of breath or wheezing. Disp: *1 * Refills: *0* <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> large left ovarian cyst, pathology pending <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> General instructions: * Take your medications as prescribed. * Do not drive while taking narcotics. * Do not combine narcotic and sedative medications or alcohol * Do not take more than 4000mg acetaminophen (APAP) in 24 hrs * No strenuous activity until your post-op appointment * Nothing in the vagina (no tampons, no douching, no sex) x 6 weeks, 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 ___. We will give you a prescription for an albuterol inhaler. You likely will need more medication or therapy for your lungs, please follow-up with pulmonology whom we have contacted on your behalf.
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Ms. ___ underwent total laparoscopic hysterectomy, bilateral salpingo-oophorectomy and cystoscopy. Please see Dr. ___ ___ for full details. Post-operatively she was admitted to the gyn oncology service. On POD#1 Ms. ___ started to have some oxygen desaturations requiring oxygen via nasal cannula. CTA on ___ revealed worsening emphysema when compared to previously but no pulmonary emboli. CXR ___ did not reveal any acute intrathoracic process. She was started on chest physical therapy and albuterol and atrovent nebulizers. By POD#3 she was able to be weaned off of oxygen. Post-operatively her BPs and finger sticks were within normal limits. By POD#3 she was able to ambulate, tolerate a regular diet, control her pain with oral pain medications and void spontaneously. She was discharged in good condition on POD#3 with follow-up.
| 1,956 | 196 |
10020728-DS-3
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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 laparoscopic hysterectomy and cystoscopy <HISTORY OF PRESENT ILLNESS> This is a ___, G2, P1, with a multi- fibroid uterus and persistent symptoms of left lower quadrant pain and some menorrhagia. <PAST MEDICAL HISTORY> PMHx: SVD x 1, GERD, hiatal hernia PSHx: open ovarian cystectomy <PHYSICAL EXAM> Upon discharge: Vital signs stable General: well appearing in no acute distress Abdominal: soft, nondistented, incisions clean, dry, and intact <PERTINENT RESULTS> SURGICAL FINDINGS: 1. Intact non ___ IUD removed at the beginning of the case. 2. A 10 week size uterus with 6 cm left posterior uterine segment fibroid extending into the broad ligament. 3. Uterus and fibroid total weight 270 g. 4. Normal-appearing ovaries bilaterally with a 2 cm simple cyst in the right ovary and normal tubes. 5. Intact bladder with bilateral ureteral jets on cysto. <MEDICATIONS ON ADMISSION> omeprazole <DISCHARGE MEDICATIONS> 1. Ibuprofen 600 mg PO Q6H: PRN Pain RX *ibuprofen 600 mg 1 tablet(s) by mouth q6 hours Disp #*50 Tablet Refills: *1 2. Oxycodone-Acetaminophen (5mg-325mg) ___ TAB PO Q4H: PRN Pain RX *oxycodone-acetaminophen 5 mg-325 mg ___ tablet(s) by mouth q4 hours Disp #*30 Tablet Refills: *0 3. MetRONIDAZOLE (FLagyl) 500 mg PO BID Duration: 7 Days RX *metronidazole [Flagyl] 500 mg 1 tablet(s) by mouth twice a day Disp #*14 Tablet Refills: *0 4. Docusate Sodium 100 mg PO BID: PRN constipation RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day Disp #*60 Capsule Refills: *2 5. Senna 8.6 mg PO BID: PRN constipation RX *sennosides [senna] 8.6 mg ___ capsule by mouth at bedtime Disp #*30 Capsule Refills: *0 6. Omeprazole 20 mg PO DAILY <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> hysterectomy for fibroids <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 after your hysterectomy and you have done well. Please follow 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. * 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 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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The patient was admitted to the gynecology service for her surgical procedure. Her intraoperative course was uncomplicated. The patient was suspected to have bacterial vaginosis and was started on flagyl for cuff dehicense prophylaxis. Upon transition to oral pain medications and meeting other postoperative milestones, the patient was discharged home in stable condition.
| 982 | 71 |
10023708-DS-20
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Codeine / Darvon / aspirin <ATTENDING> ___ <CHIEF COMPLAINT> Left adnexal mass <MAJOR SURGICAL OR INVASIVE PROCEDURE> Laparascopy converted to open Total Abdominal Hysterectomy Bilateral Salpingo-oophorectomy Omentectomy Peritoneal biopsy <HISTORY OF PRESENT ILLNESS> Ms. ___ is an ___ yo who was taken to the emergency department for symptoms of near syncope, nausea and vomiting, and a CT scan revealed a 3.9 cm solid, vascular mass in the left adnexa on ___. This was followed up with an ultrasound, which confirmed a 3.7x3.9x3.1cm solid, heterogeneous and vascular mass with irregular borders. She denies abdominal pain or bloating, N/V, vaginal bleeding, urinary symptoms or changes in bowel habits. She does note weight loss since ___, but she has attributed this to metformin and stress. Surgical management was recommended. Patient was agreeable to the plan and all consents were signed. <PAST MEDICAL HISTORY> PMH: HTN, ___ diagnosed ___, anxiety/depression (recent). Denies h/o thromboembolic disorder. PSH: D&C ___ secondary to irregular bleeding, cholecystectomy via laparotomy ___, right ankle ORIF ___. OB: G2P2, NVD x2 GYN: Menarche age ___, menopause mid-___. H/O fibroids. Denies h/o previous ovarian cysts, STI or abnormal pap. <SOCIAL HISTORY> ___ <FAMILY HISTORY> Paternal cousin died of breast cancer age ___. Maternal cousin ALS. Multiple family members have HTN, ___ and CAD. Denies family history of ovarian cancer, endometrial cancer and colon cancer. <PHYSICAL EXAM> On discharge No acute distress. Appears stated age Regular rate and rhythm. No murmurs, rubs or gallops Lungs were clear to auscultation bilaterally but with some decreased effort Abdomen was soft and non-distended. Incision with staples was clean, dry and intact. No evidence of infection Extremities were non-tender and non-edematous <PERTINENT RESULTS> ___ 07: 10AM BLOOD WBC-16.8* RBC-4.61 Hgb-12.6 Hct-38.8 MCV-84 MCH-27.4 MCHC-32.6 RDW-14.3 Plt ___ ___ 07: 10AM BLOOD Glucose-185* UreaN-13 Creat-0.7 Na-134 K-4.4 Cl-97 HCO3-28 AnGap-13 ___ 07: 10AM BLOOD Calcium-9.1 Phos-4.1 Mg-1.7 ___ 07: 50AM BLOOD WBC-14.3* RBC-4.38 Hgb-12.0 Hct-37.1 MCV-85 MCH-27.4 MCHC-32.2 RDW-13.9 Plt ___ ___ 07: 40AM BLOOD WBC-11.8* RBC-4.54 Hgb-12.2 Hct-38.4 MCV-85 MCH-26.9* MCHC-31.8 RDW-13.6 Plt ___ ___ 07: 57AM BLOOD WBC-15.3* RBC-5.06 Hgb-13.7 Hct-43.0 MCV-85 MCH-27.2 MCHC-31.9 RDW-13.8 Plt ___ ___ 07: 50AM BLOOD Glucose-123* UreaN-11 Creat-0.7 Na-137 K-4.1 Cl-98 HCO3-30 AnGap-13 ___ 07: 40AM BLOOD Glucose-93 UreaN-8 Creat-0.6 Na-141 K-3.3 Cl-101 HCO3-30 AnGap-13 ___ 07: 57AM BLOOD Glucose-145* UreaN-8 Creat-0.7 Na-141 K-3.3 Cl-99 HCO3-30 AnGap-15 ___ 07: 40AM BLOOD Calcium-8.8 Phos-1.9* Mg-1.8 ___ 07: 57AM BLOOD Calcium-9.4 Phos-2.4* Mg-2.1 ___ 07: 50AM BLOOD Calcium-8.9 Phos-3.1 Mg-1.8 <MEDICATIONS ON ADMISSION> - Amlodipine 10mg daily - Metformin 250mg twice daily - Simvastatin 20mg daily - Lorazepam 0.5mg twice daily as needed - zolpidem ___ every night as needed <DISCHARGE MEDICATIONS> 1. amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 2. ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed for pain. Disp: *30 Tablet(s)* Refills: *0* 3. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours): please do not exceed 4g of acetaminophen in 24 hours. Disp: *120 Tablet(s)* Refills: *2* 4. hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q3H (every 3 hours) as needed for pain. Disp: *20 Tablet(s)* Refills: *0* 5. docusate sodium 100 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. Disp: *60 Tablet(s)* Refills: *2* 6. metoclopramide 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for nausea: please hold for restlessness or any muscle stiffness. Disp: *30 Tablet(s)* Refills: *0* 7. metformin Oral 8. simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day. <DISCHARGE DISPOSITION> Home With Service Facility: ___ <DISCHARGE DIAGNOSIS> Left adnexal mass Final Pathology pending <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> You were admitted to the gynecologic oncology service after undergoing the procedures listed below. You have recovered well after your operation, and the team feels that you are safe to be discharged home. Please follow these instructions: General instructions: * Take your medications as prescribed. * Do not drive while taking narcotics. * Do not combine narcotic and sedative medications or alcohol * Do not take more than 4000mg acetaminophen (APAP) in 24 hrs * No strenuous activity until your post-op appointment * Nothing in the vagina (no tampons, no douching, no sex), no heavy lifting of objects >10lbs for 6 weeks. * You may eat a regular diet Incision care: * You may shower and allow soapy water to run over incision; no scrubbing of incision. No bath tubs for 6 weeks. * If you have staples, they will be removed at your follow-up visit. To reach medical records to get the records from this hospitalization sent to your doctor at home, call ___.
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Ms. ___ was admitted into the gynecology oncology service for routine post-operative care following her laparascopy converted to total abdominal hysterectomy, bilateral salpingo-oophorectomy, omentectomy, peritoneal biopsy for left adnexal mass. Her case was uncomplicated. Please refer to operative note for full details of the procedure. #1 Routine Post-op In the PACU, Ms. ___ had an epidural placed and is being followed by acute pain services. Her pain was well controlled. The epidural was discontinued on post-operative day 2. Her nausea responded to reglan and her diet was therefore advanced and she was transitioned to oral pain medications without any problems. On the ___ nighf after surgery, Ms. ___ had a desaturation to 83% on room air, which responed to oxygen via nasal canula to 96%/2L. She was not tachycardic and her lower extremities were not swollen or tender. She also denied any chest pain or shortness of breath. She got a chest x-ray, which demonstrated low lung volumes. Aggressive IS, head elevation and ambulating was recommended and she was slowly weaned off the oxygen without any difficulties. Ms. ___ finally ambulated on post-operative day 3 without difficulty. Her foley was therefore discontinued on post-op day 3 and she voided without difficulty. #2 Hypertension/Type 2 diabetes/Hyperlipidemia Ms. ___ was placed on an insulin sliding scale. Her fingersticks were elevated on the first night in the 250s and her sliding scale was adjusted as necessary and they improved. She was restarted on her antihypertensives on post-operative day 1. She was also asked to restart her metformin upon discharge and simvastatin upon discharge. #3 Persistent Nausea Ms. ___ complained of persistent nausea, which only finally responded to intravenous reglan on post-op day 2. She was transitioned to oral reglan as soon as she was tolerating a regular diet. Her electrolytes were monitored daily and repleted as needed. She was discharged on post-operative day 4 in good condition, tolerating a regular diet, voiding, ambulating and with home ___ and physical therapy for evaluation of safety at home.
| 1,682 | 478 |
10028683-DS-3
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Beta-Blockers (Beta-Adrenergic Blocking Agts) <ATTENDING> ___ <CHIEF COMPLAINT> abdominal pain <MAJOR SURGICAL OR INVASIVE PROCEDURE> Laparoscopic evacuation of blood clot, cauterization of surgical sites, hysteroscopy and dilation and curettage. <HISTORY OF PRESENT ILLNESS> ___ yo G2P2 presents post-op day 3 after laparoscopic salpingectomies with severe abdominal pain. <PAST MEDICAL HISTORY> OBHx G2P2-0-0-2. GYN HX: Menarche age ___. - Irregular menses with menometrorrhagia ___ bleeding episodes per month) with heavy flow. LMP ___. - last PAP (___): neg SIL, +LR HPV, -HR HPV. - s/p Essure HSC permanent sterilization in ___, now s/p LSC removal on ___ - Denies history of any STDs. PMHx: endometriosis, asthma, migraines, chronic constipation, B12 defcy, AUB, recurrent vag candidiasis PSHx: ___, laparoscopy ?fulguration of endometriosis at ___ in ___ and ___, Essure ___, laparoscopic excision of endometriosis ___, b/l salpingectomies as noted <SOCIAL HISTORY> ___ <FAMILY HISTORY> NC <PHYSICAL EXAM> on presentation: 98.6 63 109/52 16 100RA Appears uncomfortable, speaking in short sentences and bracing herself against gurney RRR CTAB Abd soft, mildly distended, diffusely TTP, mild rebound, no guarding, incisions c/d/i, no erythema Ext WWP, no edema Pelvic copious dark blood in vault, unable to visualize cervix, small anteverted uterus but difficult to examine given severe abdominal tenderness, no adnexal masses Labs 6.7 > 31.8 < 234 PMNs 62.5 no bands INR 1.0 PTT 26.9 ___ 10.8 143 | 105 | 8 ---------------< 101 3.5 | 26 | 0.___bd/pel w contrast Wet read: 1. Moderate blood within the pelvis. No evidence of extravasation of contrast. 2. No evidence of uterine rupture, although ultrasound is more sensitive for the detection of uterine rupture. 3. No evidence of bowel obstruction or ileus. <PERTINENT RESULTS> hematocrit: pre-op Hct 42 -> 31 -> 28 -> 24 -> 29 -> ___ prior to discharge <MEDICATIONS ON ADMISSION> albuterol, fluticasone, ibuprofen, reglan, zofran, percocet, valtrex, colace <DISCHARGE MEDICATIONS> home meds plus: 1. HYDROmorphone (Dilaudid) 2 mg PO Q4H: PRN pain Do not drive while taking this medication. RX *hydromorphone 2 mg 1 tablet(s) by mouth every four (4) hours Disp #*25 Tablet Refills: *0 2. Acetaminophen ___ mg PO Q6H: PRN pain Do not take more than 4000mg in one day. RX *acetaminophen 500 mg 1 to 2 tablet(s) by mouth every six (6) hours Disp #*40 Tablet Refills: *2 3. Docusate Sodium 100 mg PO BID Take while using dilaudid to prevent constipation. RX *docusate sodium 100 mg 1 capsule(s) by mouth BOD Disp #*60 Capsule Refills: *2 <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> hemoperitoneum <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 * 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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Ms. ___ was readmitted 3 days after laparoscopic bilateral salpingectomies with severe abdominal pain, vaginal bleeding, evidence of hemoperitoneum and falling hematocrit. She was urgently taken back to OR for diagnostic laparoscopy. All surgical sites were noted to be hemostatic but there was 500cc of hemoperitoneum. This was evacuated and surgical sites reinforced. Given no signficiant source identified, she also underwent hysteroscopy (findings: normal cavity) and D&C. Differential diagnosis includes uterine bleeding (menorrhagia) with retrograde flow through cornual surgical sites or resolved surgical bleeding with similar cornual communication and transvaginal passage. She was observed overnight and hematocrit was stable. She was discharged to home in good condition.
| 1,237 | 169 |
10030852-DS-18
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> poor diabetes control <MAJOR SURGICAL OR INVASIVE PROCEDURE> none <HISTORY OF PRESENT ILLNESS> ___ G1 with T1DM at 32w3d who presents for admission due to poorly controlled diabetes. Pt has been followed by her endocrinologist (Dr ___ but has been poorly controlled for most of the pregnancy. She is a poor historian, unable to give range of her ___ values. States "it depends on the day." She had a CGM which has been falling off her abdomen recently so she hasn't been using it. This morning her ___ was 182 when she woke up. She is not sure of her pump settings, but states she could look at her pump to see them. States her endocrinologist makes the changes for her. She was last seen by Dr ___ 1 week ago. Pt denies any fevers/chills, urinary symptoms, n/v/d. Denies contractions, LOF, or VB. Reports active FM. <PAST MEDICAL HISTORY> PNC: *) ___ ___ by LMP c/w 7wk U/S *) Labs: A+/Ab-,RI,GC/CT-,RPRnr,HbsAg-,HIV-,GBS unk *) nl FFS, anterior placenta, nl sequential screen, per pt nl, fetal echo at 23 weeks at CHB *) s/p flu and Tdap ISSUES: *) obesity, current weight 260# *) acute appendicitis at 16wks, s/p lap appendectomy *) T1DM: (dx'd at ___ - s/p multiple admissions for DKA in past (most recent ___ - on Meditronic pump for ___ years - endocrinologist: Dr ___ - nl fetal echo (___) - nl baseline ___ labs, has not done 24hr urine yet - ___ 1911g(68%); AC 84% - HbA1C ~13% at conception per pt (according to PN records) - ___ 8% - ___ 1.78 - UTI in early pregnancy treated ObHx: G1 current GynHx: - LGSIL pap (___) -> for rpt in ___ year - vulvar condyloma, s/p TCA PMH: T1DM dx age ___, on inulin pump ___ year SurgHx: lap appendectomy (___) <SOCIAL HISTORY> ___ <FAMILY HISTORY> mother and father with T2DM <PHYSICAL EXAM> Admission PE VS: BP 126/70, 88, 18, afebrile. ___ 226 (has pump on now) Gen: appears comfortable, NAD Lungs: CTAB Heart: RRR Abd: soft, gravid, NT FHT: 140s, mod var, +accels, no decels Toco: no ctxs Discharge PE VSS Gen: appears comfortable, NAD Lungs: CTAB Heart: RRR Abd: soft, gravid, NT <PERTINENT RESULTS> ___ 04: 30PM URINE COLOR-Yellow APPEAR-Clear SP ___ ___ 04: 30PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30 GLUCOSE-1000 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-NEG ___ 04: 30PM URINE RBC-0 WBC-1 BACTERIA-NONE YEAST-NONE EPI-3 ___ 04: 30PM URINE AMORPH-RARE ___ 04: 30PM URINE MUCOUS-RARE ___ 03: 30PM GLUCOSE-196* UREA N-9 CREAT-0.4 SODIUM-133 POTASSIUM-4.0 CHLORIDE-100 TOTAL CO2-20* ANION GAP-17 ___ 03: 30PM estGFR-Using this ___ 03: 30PM CALCIUM-8.9 PHOSPHATE-3.3 MAGNESIUM-1.7 ___ 03: 30PM WBC-8.9 RBC-4.24 HGB-12.2 HCT-36.2 MCV-85 MCH-28.8 MCHC-33.7 RDW-12.5 RDWSD-38.5 ___ 03: 30PM PLT COUNT-329 <MEDICATIONS ON ADMISSION> Insulin pump, PNV, ASA <DISCHARGE MEDICATIONS> 1. Mastisol Adhesive (gum mastic-storax-msal-alcohol) 1 package to skin prn RX *gum mastic-storax-msal-alcohol apply to skin as needed Disp #*3 Bottle Refills: *5 2. Insulin Pump SC (Self Administering Medication)Insulin Lispro (Humalog) Basal Rates: Midnight - 0200: .85 Units/Hr 0200 - 0600: 1.1 Units/Hr 0600 - 0900: 2.4 Units/Hr 0900 - 1200: 2.4 Units/Hr 1200 - 1500: 1.8 Units/Hr 1500 - 1800: 1.7 Units/Hr 1800 - 2100: 2 Units/Hr ___ - 0000: 1.5 Units/Hr Meal Bolus Rates: Breakfast = 1: 2 Lunch = 1: 4 Dinner = 1: 2 High Bolus: Correction Factor = 1: 12 Correct To ___ mg/dL 3. Aspirin 81 mg PO DAILY 4. Prenatal Vitamins 1 TAB PO DAILY <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> pregnancy at 32 weeks gestation poorly controlled T1DM <DISCHARGE CONDITION> stable <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> You were admitted to the antepartum floor for management of your diabetes. The endocrinologists from ___ met with you and made changes in your insulin regimen. Your fingersticks improved significantly and it was felt it was safe for you to be discharged. Fetal testing was reassuring while you were here. You had an eye exam which revealed no evidence of retinopathy.
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Ms. ___ was admitted on ___ for poorly controlled TIDM and glycemic control. She had no signs or symptoms of DKA on arrival, and had reassuring lab results. She was connected with ___, who followed her during her stay. Her pump settings were adjusted and she received pump teaching. She also had an eye exam done in the ophthalmology clinic on ___ with no signs of diabetic retinopathy. A baseline 24hr urine was done and was 231mg. She also obtained a formal ultrasound that demonstrated mild polyhydramnios with MVP 8.6, EFW 2181g(84%), AC 84%. She was recommended for twice weekly testing based on her polyhydramnios and T1DM. Her glycemic control improved and she was discharged in stable condition on ___ with adjusted pump settings.
| 1,390 | 174 |
10030852-DS-19
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> diabetic ketoacidosis with history of Type I diabetes ___ ___ <MAJOR SURGICAL OR INVASIVE PROCEDURE> none <HISTORY OF PRESENT ILLNESS> ___ G1 at ___ with T1DM transferred for poorly controlled diabetes. She reports her finger sticks have been more poorly controlled over the past ___ days, reporting fasting FSBG around 200s and pre-prandial lunch/dinner FSBG in 160s-200s. She last changed her insulin pump site ___ days ago because it was falling off; it is currently on her L outer thigh. She denies concerns for pump malfunction. She has been checking her FSBG 3x/day (fasting, pre-lunch, and pre-dinner) but does not check at bedtime or in the middle of the night. Pt presented for a routine OB visit during which she reported recent poor control of her sugars, and was recommended to present to ___. Initial ___ there was 345, and she was bolused 16.2 units through her pump in the late afternoon. No other changes were made to her current pump settings. All ___ there were over 200. Per notes, she was to receive a 1L IVF bolus, however, pt denies receiving any IVF there. She underwent serum and urine labs that were notable for: Na 132, K 3.6, anion gap 13, serum osmolality 285, + serum and urine ketones. She was transferred to ___ for admission for glucose control. <PAST MEDICAL HISTORY> PNC: *) ___ ___ by LMP c/w 7wk U/S *) Labs: A+/Ab-,RI,GC/CT-,RPRnr,HbsAg-,HIV-,GBS unk *) nl FFS, anterior placenta, nl sequential screen, per pt nl, fetal echo at 23 weeks at CHB *) s/p flu and Tdap ISSUES: *) obesity, current weight 260# *) acute appendicitis at 16wks, s/p lap appendectomy *) T1DM: (dx'd at ___ - s/p multiple admissions for DKA in past (most recent ___ - on Meditronic pump for ___ years - endocrinologist: Dr ___ - nl fetal echo (___) - nl baseline ___ labs, has not done 24hr urine yet - ___ 1911g(68%); AC 84% - HbA1C ~13% at conception per pt (according to PN records) - ___ 8% - ___ 1.78 - UTI in early pregnancy treated ObHx: G1 current GynHx: - LGSIL pap (___) -> for rpt in ___ year - vulvar condyloma, s/p TCA PMH: T1DM dx age ___, on inulin pump ___ year SurgHx: lap appendectomy (___) <SOCIAL HISTORY> ___ <FAMILY HISTORY> mother and father with T2DM <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, +1 edema FHR: present at a normal rate <PERTINENT RESULTS> ___ 09: 15AM BLOOD WBC-6.0 RBC-4.03 Hgb-11.3 Hct-34.2 MCV-85 MCH-28.0 MCHC-33.0 RDW-12.9 RDWSD-39.9 Plt ___ ___ 12: 08AM BLOOD WBC-7.7 RBC-3.77* Hgb-10.5* Hct-31.7* MCV-84 MCH-27.9 MCHC-33.1 RDW-12.7 RDWSD-38.6 Plt ___ ___ 10: 14AM BLOOD WBC-6.7 RBC-3.69* Hgb-10.3* Hct-31.0* MCV-84 MCH-27.9 MCHC-33.2 RDW-12.6 RDWSD-38.2 Plt ___ ___ 01: 30AM BLOOD WBC-8.4 RBC-4.19 Hgb-11.6 Hct-35.6 MCV-85 MCH-27.7 MCHC-32.6 RDW-12.6 RDWSD-38.5 Plt ___ ___ 01: 38AM BLOOD ___ PTT-25.7 ___ ___ 09: 15AM BLOOD Glucose-73 UreaN-3* Creat-0.4 Na-138 K-3.6 Cl-109* HCO3-18* AnGap-15 ___ 12: 08AM BLOOD Glucose-92 UreaN-5* Creat-0.4 Na-136 K-3.7 Cl-108 HCO3-15* AnGap-17 ___ 03: 25PM BLOOD Glucose-112* UreaN-5* Creat-0.4 Na-138 K-3.7 Cl-111* HCO3-15* AnGap-16 ___ 10: 14AM BLOOD Glucose-106* UreaN-6 Creat-0.4 Na-137 K-3.7 Cl-109* HCO3-16* AnGap-16 ___ 05: 23AM BLOOD Glucose-119* UreaN-6 Creat-0.4 Na-136 K-3.6 Cl-110* HCO3-15* AnGap-15 ___ 01: 30AM BLOOD Glucose-211* UreaN-7 Creat-0.5 Na-131* K-3.7 Cl-100 HCO3-15* AnGap-20 ___ 01: 30AM BLOOD ALT-12 AST-13 Amylase-16 ___ 01: 30AM BLOOD Lipase-28 ___ 09: 15AM BLOOD Calcium-8.1* Phos-2.5* Mg-1.8 ___ 12: 08AM BLOOD Calcium-7.9* Phos-2.4* Mg-1.9 ___ 03: 25PM BLOOD Calcium-7.5* Phos-2.3* Mg-1.9 ___ 10: 14AM BLOOD Calcium-7.4* Phos-1.9* Mg-1.5* ___ 05: 23AM BLOOD Calcium-7.2* Phos-1.8* Mg-1.4* ___ 01: 30AM BLOOD Calcium-8.2* Phos-2.5* Mg-1.7 UricAcd-5.6 ___ 05: 23AM BLOOD Acetone-NEGATIVE Osmolal-279 ___ 01: 30AM BLOOD Acetone-NEGATIVE Osmolal-284 ___ 01: 30AM BLOOD TSH-6.6* ___ 01: 30AM BLOOD Free T4-1.1 ___ 05: 23AM BLOOD RedHold-HOLD ___ 06: 40AM BLOOD Type-ART pO2-102 pCO2-26* pH-7.39 calTCO2-16* Base XS--7 ___ 06: 44AM URINE Color-Yellow Appear-Hazy Sp ___ ___ 03: 01AM URINE Color-Yellow Appear-Clear Sp ___ ___ 08: 44PM URINE Color-Straw Appear-Clear Sp ___ ___ 06: 44AM URINE Blood-NEG Nitrite-NEG Protein-30 Glucose-1000 Ketone-150 Bilirub-NEG Urobiln-2* pH-6.0 Leuks-SM ___ 03: 01AM URINE Blood-NEG Nitrite-NEG Protein-30 Glucose-1000 Ketone-150 Bilirub-NEG Urobiln-2* pH-6.0 Leuks-NEG ___ 08: 44PM URINE Blood-NEG Nitrite-NEG Protein-TR Glucose-1000 Ketone-150 Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG ___ 06: 44AM URINE RBC-2 WBC-7* Bacteri-NONE Yeast-NONE Epi-10 ___ 03: 01AM URINE RBC-1 WBC-2 Bacteri-FEW Yeast-NONE Epi-2 ___ 08: 44PM URINE RBC-0 WBC-0 Bacteri-NONE Yeast-NONE Epi-1 ___ 06: 44AM URINE CastHy-2* ___ 03: 01AM URINE CastHy-1* ___ 03: 01AM URINE Hours-RANDOM Creat-115 TotProt-46 Prot/Cr-0.4* ___ 03: 01AM URINE Osmolal-1042 ___ 3: 01 am URINE Source: ___. **FINAL REPORT ___ URINE CULTURE (Final ___: MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION <MEDICATIONS ON ADMISSION> Humalog pump, PNV, ASA 81mg daily <DISCHARGE MEDICATIONS> 1. Insulin Pump SC (Self Administering Medication)Insulin Lispro (Humalog) Basal Rates: Midnight - 0200: 1.05 Units/Hr 0200 - 0600: 1.3 Units/Hr 0600 - 1200: 2.4 Units/Hr 1200 - 1500: 2 Units/Hr 1500 - 1800: 1.9 Units/Hr 1800 - 2100: 2.4 Units/Hr ___ - 0000: 1.65 Units/Hr Meal Bolus Rates: Breakfast = 1: 2 Lunch = 1: 4 Dinner = 1: 2 Snacks = 1: 2 High Bolus: Correction Factor = 1: 12 Correct To ___ mg/dL MD acknowledges patient competent MD has ordered ___ consult 2. Prenatal Vitamins 1 TAB PO DAILY <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> DKA T1DM 34 weeks gestational age <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 DKA and management of your T1DM. Your diabetes control was improved and you are now safe to be discharged home.
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On ___, Ms. ___ G1P0 at 34wks, was admitted to the anteapartum service with concern for diabetic ketoacidosis in the setting of T1DM with insulin pump. Workup was negative for infectious process and presentation likely secondary to pump failure. She was initiated on an insulin drip and received IVF hydration with subsequent normalization of blood glucose and resolution of anion gap. Her diet was advanced and she was transitioned to her insulin pump. She continued to have fasting blood sugars at goal. On HD#2, her insulin pump fell out and she again received insulin drip until her pump was replaced and she was able to be transitioned. By hospital day 3, she was on her insulin pump regularly with controlled blood glucose levels. She was then discharged in stable condition with appropriate pump settings. Of note, she had an ultrasound on ___ with BPP ___ and AFI within normal limits.
| 2,403 | 189 |
10030852-DS-20
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> Elevated BPs <MAJOR SURGICAL OR INVASIVE PROCEDURE> Vacuum-assisted vaginal delivery <HISTORY OF PRESENT ILLNESS> ___ G1P0 at 36w3d with poorly controlled ___ transferred from ___ with elevated BPs. She had BPs 172/101 and 164/80 at ___ followed by mild range BPs and did not receive IV antihypertensive medications. She had PIH labs that were wnl except for urine P: C of 0.47. Her FSG were well controlled there. She was given magnesium 6g bolus and transferred to ___. Late preterm betamethasone was deferred given h/o poorly controlled T1DM. On admission, she reports feeling well other than cold symptoms that she has had for a few days. She reports a moderate HA and has not taken Tylenol. Denies vision changes or epig pain. Denies ctx, VB, LOF, reports AFM. Denies nausea, vomiting, abdominal pain. Of note, she was admitted to ___ twice during this pregnancy for poorly controlled diabetes and concern for DKA. She reports her pump has been working well recently. ROS: Denies fevers/chills. Denies vision changes. Denies chest pain/shortness of breath/palpitations. Denies abdominal pain. Denies recent falls or abdominal trauma. Denies any unusual foods/undercooked foods, nausea, vomiting, diarrhea. PNC: - ___ ___ by LMP c/w 7wk U/S - Labs: A+/Ab-,RI,GC/CT-,RPRNR,HbsAg-,HIV-,GBS pnd (collected ___ - Screening: low risk sequential screen - FFS: wnl, anterior placenta - Vaccines: s/p flu and Tdap - Ultrasound ___ (at ___: 2181g, 59%, mildly increased AFI, MVP 8.6cm - Ultrasound ___ (at ___: 2777gm, 74%, AFI 16.9, BPP ___ - Issues: *) obesity, current weight 260# *) acute appendicitis at 16wks, s/p LSC appendectomy *) UTI in early pregnancy, treated *) ? Polyhydramnios: MVP 8.6cm on ___, but normal AFI 16.9 on ___ *) T1DM: - diagnosed at ___ - s/p multiple admissions for DKA in past (most recent ___ pre-pregnancy, ___ in pregnancy) - on Meditronic pump for ___ years - endocrinologist: Dr ___ - nl fetal echo (___) - nl baseline ___ labs, 24hr urine 231mg (___) - s/p optho c/s ___, no e/o diabetic retinopathy - HbA1C ~13% at conception per pt (according to ___ records) - ___ 8% - ___ 1.78 *) ___ ante admission ___ and ___: ___ consult, insulin pump adjusted, s/p pump teaching. s/p optho consult, no e/o diabetic retinopathy. s/p nutrition consult. <PAST MEDICAL HISTORY> OBHx: G1 current GynHx: - LGSIL pap (___) -> for rpt in ___ year - vulvar condyloma, s/p TCA PMHx: - T1DM dx age ___, on inulin pump ___ year - Obesity PSHx: lsc appendectomy (___) Meds: Humalog pump, PNV, ASA 81mg daily <SOCIAL HISTORY> ___ <FAMILY HISTORY> mother and father with T2DM <PHYSICAL EXAM> 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> ___ 10: 23PM BLOOD WBC-9.0 RBC-3.50* Hgb-9.5* Hct-28.7* MCV-82 MCH-27.1 MCHC-33.1 RDW-12.7 RDWSD-38.1 Plt ___ ___ 07: 57PM BLOOD WBC-8.1 RBC-3.53* Hgb-9.2* Hct-29.1* MCV-82 MCH-26.1 MCHC-31.6* RDW-12.7 RDWSD-38.4 Plt ___ ___ 10: 15AM BLOOD WBC-8.5 RBC-3.67* Hgb-9.9* Hct-30.1* MCV-82 MCH-27.0 MCHC-32.9 RDW-12.6 RDWSD-38.0 Plt ___ ___ 01: 55AM BLOOD WBC-7.9 RBC-3.50* Hgb-9.3* Hct-28.6* MCV-82 MCH-26.6 MCHC-32.5 RDW-12.7 RDWSD-38.3 Plt ___ ___ 06: 49PM BLOOD WBC-7.0 RBC-3.54* Hgb-9.6* Hct-29.2* MCV-83 MCH-27.1 MCHC-32.9 RDW-12.6 RDWSD-38.5 Plt ___ ___ 12: 18PM BLOOD WBC-7.4 RBC-3.71* Hgb-10.0* Hct-30.5* MCV-82 MCH-27.0 MCHC-32.8 RDW-12.6 RDWSD-37.7 Plt ___ ___ 04: 15AM BLOOD WBC-7.3 RBC-3.57* Hgb-9.7* Hct-29.5* MCV-83 MCH-27.2 MCHC-32.9 RDW-12.4 RDWSD-38.0 Plt ___ ___ 09: 00PM BLOOD WBC-8.2 RBC-3.75* Hgb-10.1* Hct-31.1* MCV-83 MCH-26.9 MCHC-32.5 RDW-12.5 RDWSD-38.4 Plt ___ ___ 10: 23PM BLOOD Creat-0.6 ___ 07: 57PM BLOOD Creat-0.5 ___ 10: 15AM BLOOD Creat-0.5 ___ 01: 55AM BLOOD Creat-0.5 ___ 06: 49PM BLOOD Creat-0.5 ___ 12: 18PM BLOOD Creat-0.5 ___ 04: 15AM BLOOD Glucose-111* UreaN-6 Creat-0.5 Na-133 K-3.7 Cl-101 HCO3-18* AnGap-18 ___ 09: 00PM BLOOD Glucose-148* UreaN-7 Creat-0.5 Na-132* K-6.1* Cl-103 HCO3-16* AnGap-19 ___ 10: 23PM BLOOD ALT-7 AST-13 ___ 07: 57PM BLOOD ALT-7 AST-13 ___ 10: 15AM BLOOD ALT-8 AST-15 ___ 01: 55AM BLOOD ALT-8 AST-13 ___ 06: 49PM BLOOD ALT-8 AST-13 ___ 12: 18PM BLOOD ALT-8 AST-15 ___ 04: 15AM BLOOD ALT-8 AST-13 ___ 09: 00PM BLOOD ALT-11 AST-43* ___ 10: 23PM BLOOD UricAcd-6.6* ___ 10: 15AM BLOOD UricAcd-5.5 ___ 01: 55AM BLOOD UricAcd-5.3 ___ 12: 18PM BLOOD Mg-4.9* UricAcd-4.7 ___ 04: 15AM BLOOD Mg-4.3* UricAcd-4.2 ___ 09: 00PM BLOOD Calcium-8.1* Phos-4.2 Mg-3.5* UricAcd-3.9 ___ 10: 04AM BLOOD Type-ART pO2-23* pCO2-53* pH-7.27* calTCO2-25 Base XS--3 Comment-CORD ___ ___ 10: 02AM BLOOD ___ pO2-80* pCO2-39 pH-7.32* calTCO2-21 Base XS--5 Comment-CORD VEIN <DISCHARGE INSTRUCTIONS> Nothing in the vagina for 6 weeks (No sex, douching, tampons) Do not drive while taking Percocet Do not take more than 4000mg acetaminophen (tylenol) in 24 hrs Do not take more than 2400mg ibuprofen in 24 hrs Please call the on-call doctor at ___ if you develop shortness of breath, dizziness, palpitations, fever of 101 or above, abdominal pain, heavy vaginal bleeding, nausea/vomiting, depression, or any other concerns.
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On ___, Ms. ___ was transferred from ___ at 36w3d with elevated BPs to the 170s/100s and P:C of 0.47. She was given a 6g Magnesium bolus at ___. Late preterm betamethasone was deferred given history of poorly controlled T1DM. Upon arrival, she was continued on magnesium infusion and reported a ___ HA treated with tylenol. For her T1DM, ___ was consulted and recommended transition from humalog pump to insulin gtt. Pt was then counseled and started on induction of labor for pre-eclampsia with severe features by blood pressure. *) Pre-eclampsia, severe by BPs Pt was continued on magnesium infusion. Her BPs ranged from normotensive to intermittently in the severe range. She was given an additional 2g bolus of Mag when Mag level returned subtherapeutic. PEC labs were trended q8 hours. She was continued on labetalol 200mg BID and uptitrated to TID. She was also kept on subcutaneous heparin for VTE prophylaxis. Her headache was treated with tylenol and compazine. During the second stage of labor, she was noted to have hematuria with adequate urine volume likely due to obstruction from fetal head. Cr was normal at 0.6. She was continued on magnesium for 24 hours postpartum and did not require continuation of labetalol in the postpartum period for BP control. *) T1DM Pt's insulin gtt and D10 were titrated per protocol during the intrapartum period. During the postpartum period, pt was transitioned from gtt to pump once taking PO. Pt was followed by ___ throughout her hospital course. *) Induction of labor She received 6 doses of PV cytotec and started on pitocin which was uptitrated per protocol. She then had a foley bulb placed and declined a second placement. Pitocin was uptitrated to 20units per protocol and maintained from ___ at 1100 to ___ at 0430. Pitocin was turned off then restarted on ___ at 0600. She was then AROM'ed at 1315. On ___ at 0030, pt was fully dilated at +1 station. She labored down for an hour, after which she pushed for 20 minutes with good effort. She then labored down again for one hour, after which she resumed pushing with variable intensity. After prolonged second stage and maternal exhaustion, pt was counseled on and underwent a vacuum assisted delivery at 0937 of a viable baby girl, complicated by shoulder dystocia x 2 minutes that resolved with McRobert's maneuver, suprapubic pressure, ___ maneuver. *) Bilateral groin pain - pt complained of bilateral groin pain in the postpartum period, likely musculoskeletal in origin due to prolonged labor course. She was seen and evaluated by physical therapy after pain was adequately controlled. She was able to ambulate without assistance upon discharge. By postpartum day 4, she was tolerating a regular diet, ambulating independently, and pain was controlled with oral medications. She was afebrile with stable vital signs. She was then discharged home in stable condition with postpartum outpatient follow-up scheduled. Discharge Medications: 1. Docusate Sodium 100 mg PO BID:PRN Constipation RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice a day Disp #*60 Capsule Refills:*1 2. Ibuprofen 600 mg PO Q6H:PRN Moderate Pain RX *ibuprofen 600 mg 1 tablet(s) by mouth every six (6) hours Disp #*40 Tablet Refills:*1 3. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Moderate to Severe Pain RX *oxycodone [Oxaydo] 5 mg 1 tablet(s) by mouth every four (4) hours Disp #*15 Tablet Refills:*0 4. Insulin Pump SC (Self Administering Medication)Insulin Lispro (Humalog) Basal Rates: Midnight - 0600: .7 Units/Hr 0600 - 0000: .8 Units/Hr Meal Bolus Rates: Breakfast = 1:8 Lunch = 1:8 Dinner = 1:8 High Bolus: Correction Factor = 1:30 Correct To ___ mg/dL Discharge Disposition: Home Discharge Diagnosis: 36 week gestation, type 1 diabetes, preeclampsia with severe features, prolonged second stage, shoulder dystocia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___
| 2,080 | 1,022 |
10030937-DS-21
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___. <CHIEF COMPLAINT> Dyspnea on exertion <MAJOR SURGICAL OR INVASIVE PROCEDURE> None <HISTORY OF PRESENT ILLNESS> ___ s/p pLTCS for arrest of dilation on ___ presents with two days of worsening shortness of breath. She describes onset of symptoms two nights ago, which she noticed as she was trying to lie down to go to bed and couldn't take a deep breath. Her SOB has gotten progressively worse over the last two days, making it difficult for her to walk more than a few feet without being symptomatic. She cannot lie flat. She is short of breath when trying to speak multiple sentences. This does not feel like her SOB associated with her asthma in the past. She has been using her inhaler excessively with no relief. She intermittently feels as if her heart is racing. Denies chest pain. Has intermittent abdominal cramping, however denies significant abdominal pain or incisional pain. Only taking Tylenol and motrin for pain; never needed oxycodone. Has had a BM. Voiding without issue; previously bloody urine has resolved. She did have a mild HA on presentation to the ED, which resolved with Tylenol. She is breastfeeding and the baby has been doing really well. <PAST MEDICAL HISTORY> OBHx: ___ - s/p pLTCS on ___ for arrest of dilation at 8cm after prolonged augmentation of labor with Pitocin following SROM GYNHx: - previously normal menstrual cycles - denies hx of abnormal Pap testing (last Pap ___ - denies hx of STIs - denies hx of GYN surgeries or procedures, aside from recent primarly LTCS - has small posterior fibroid (2z2x2cm) PMHx: - migraine HA - asthma PSHx: - pLTCS Medications: albuterol inhaler All: NKDA <SOCIAL HISTORY> ___ <FAMILY HISTORY> Denies hypertensive disease in her family, bleeding disorders or history of blood clots. <PHYSICAL EXAM> Physical Exam on Admission: 98.7 HR83 BP149/95 RR20 O2sat 100% RA 97.81 HR74 BP 148/100 RR16 O2sat 100% RA 98.1 HR86 BP151/89 RR22 O2sat 100% RA Gen: NAD CV: mild tachycardia, regular rhythm Pulm: mild increased work of breathing, tachypneaic at rest; mildly decreased breath sounds at bilateral bases, no wheezes appreciated, no crackles appreciated Abd: softly distended, appropriately mildly TTP, fundus firm, incision c/d/I, no drainage or bleeding GU: pad w/mild spotting Ext: WWP, no edema or tenderness appreciated of ___ _ ________________________________________________________________ Physical Exam on Discharge: 24 HR Data (last updated ___ @ 315) Temp: 99.7 (Tm 100.8), BP: 149/90 (127-152/79-99), HR: 87 (71-90), RR: 18, O2 sat: 95% (95-97), O2 delivery: Ra Fluid Balance (last updated ___ @ 2305) Last 8 hours No data found Last 24 hours Total cumulative -345ml IN: Total 840ml, PO Amt 840ml OUT: Total 1185ml, Urine Amt 1185ml General: Sitting up in bed in no acute distress, A&Ox3 Breasts: soft, non-tender, no erythema, soft, no focal areas of induration, fluctuance, or tenderness, nipples intact Lungs: Lungs clear to auscultation bilaterally, no wheezes or crackles Abd: soft, nontender, fundus firm below umbilicus Incision: clean, dry, intact, no erythema/induration, dressed in steri-strips stained with serosanguinous fluid Extremities: no calf tenderness, no edema <PERTINENT RESULTS> ___ 11: 12AM BLOOD WBC-7.9 RBC-3.55* Hgb-9.4* Hct-29.5* MCV-83 MCH-26.5 MCHC-31.9* RDW-14.4 RDWSD-42.9 Plt ___ ___ 12: 20PM BLOOD Neuts-72.5* ___ Monos-4.8* Eos-0.8* Baso-0.3 NRBC-0.4* Im ___ AbsNeut-5.50 AbsLymp-1.52 AbsMono-0.36 AbsEos-0.06 AbsBaso-0.02 ___ 05: 10AM BLOOD Glucose-78 UreaN-10 Creat-0.8 Na-141 K-3.9 Cl-106 HCO3-20* AnGap-15 ___ 11: 12AM BLOOD ALT-59* AST-26 ___ 12: 20PM BLOOD cTropnT-<0.01 ___ 12: 20PM BLOOD cTropnT-<0.01 ___ 12: 20PM BLOOD proBNP-631* ___ 02: 22PM BLOOD pO2-22* pCO2-37 pH-7.40 calTCO2-24 Base XS--1 Comment-ABG ADDED CTA Chest (___): 1. No evidence of pulmonary embolism or aortic abnormality. 2. Bilateral multifocal nodular ground-glass opacities likely represents moderate pulmonary edema, in the setting of cardiomegaly and bilateral pleural effusions. CXR ___, prelim read): Right greater than left bilateral perihilar opacities are worrisome for asymmetric pulmonary edema, moderate to severe on the right and moderate on the left. Pulmonary hemorrhage not excluded. Trace right greater than left pleural effusions. EKG (___): Normal sinus rhythm ___ (___): No evidence of deep venous thrombosis in the right lower extremity veins. Transthoracic Echocardiogram (___): Normal global and regional biventricular systolic function. Mild mitral and tricuspid regurgitation. Mild pulmonary hypertension. <MEDICATIONS ON ADMISSION> Albuterol inhaler Ibuprofen Acetaminophen <DISCHARGE MEDICATIONS> 1. Ibuprofen 600 mg PO Q6H: PRN Pain - Mild/Fever NOT relieved by Acetaminophen RX *ibuprofen [IBU] 600 mg 1 tablet(s) by mouth q 6 hours prn pain Disp #*40 Tablet Refills: *0 2. Labetalol 200 mg PO BID RX *labetalol 200 mg 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills: *0 3. Ferrous Sulfate 325 mg PO BID <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> ___ s/p pLTCS ___ re-admitted with dyspnea on exertion, orthopnea, dx w GHTN (started labetolol) and seen by cardiology and cleared. Fever from engorgement <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> see ob sheet
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Ms. ___ was readmitted to the Postpartum service after she presented to the Emergency Department with dyspnea on exertion. Thorough workup in the ED found mild pulmonary edema on chest x-ray, and was otherwise negative for acute cardiac or pulmonary etiology. For this, she was given one dose of IV furosemide which helped relieve her symptoms before readmission. On the Postpartum floor, she was comfortable on exam, though still with symptoms of dyspnea on exertion. She complained of a mild headache improved with ibuprofen and acetaminophen and eating, and was well overnight. Two times over the course of her admission, Ms. ___ had a fever, to 101.1 and 100.8, respectively. Thorough evaluation for fever etiology was negative, though Ms. ___ had been breast pumping and feeding intermittently since undergoing CT in the ED, making engorgement the most probable etiology. On night 2 of her admission, Ms. ___ received a second dose of IV furosemide for further improved symptoms, and the next day received a transthoracic echocardiogram without evidence of peripartum cardiomyopathy. By hospital day 3, she was symptomatically improved and continuing to meet all postpartum and self-care milestones, and was deemed safe for discharge with plan for follow up with peripartum cardiology.
| 1,653 | 291 |
10033159-DS-5
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Patient recorded as having No Known Allergies to Drugs <ATTENDING> ___. <CHIEF COMPLAINT> LLQ pain <MAJOR SURGICAL OR INVASIVE PROCEDURE> Ultrasound guided tuboovarian absess drainage <HISTORY OF PRESENT ILLNESS> This is a ___ G0 with no significant PMH presenting with 10 days of LLQ pain, fever and chills. The pain began 10 days PTA. It is a crampy intermittent pain localized to the LLQ, ranging in severity from ___. It does not radiate, and is partially relieved by tylenol. She has noted fevers, with a temperature of 103.8 9d PTA and readings around 101 over the past several days. She also complains of chills, night sweats, decreased appetite and constipation. Last bowel movement today. She denies lightheadedness, blood in her bowel mvts, dysuria, hematuria, or increased frequency. She denies changes in her menstrual periods, her LMP was ___. She is sexually active with one partner and uses condoms. No abnl vaginal discharge or spotting. <PAST MEDICAL HISTORY> PMHx: Trichilomania (diagnosed as a child, not very active at present) PSHx: Wisdom teeth several years ago. PGYNHx: - LMP ___. Regular 30 day cycle, no dysmenorrhea. - Last pap ___. No history of abnormal paps. - No hx of chlamydia, gonorrhea, HSV. - Currently sexually active with 1 partner, monogamous, uses condoms, together for several months. <SOCIAL HISTORY> ___ <FAMILY HISTORY> No known history of gynecologic or obstetric disease. <PHYSICAL EXAM> (done by Dr ___ Tmax 99.4, 84, 107/64, 18, 100% RA HEENT: Moist mucous membranes. Pulm: CTAB CV: RRR, no m/r/g. Abd: Nondistended, +BS, tender to deep palpation over the LLQ. No CVA tenderness. No guarding or rebound tenderness. No stool in the rectal vault. Guiac negative. Pelvic: Normal external genitalia. Speculum exam is unremarkable. No cervical motion tenderness. Midline uterine fundus. Fullness in the left adnexa. Ext: Warm and well perfused. <PERTINENT RESULTS> ___ CBC: 12.9>35.7<556 Lytes: ___ CRP: 155 ___ 10: 30AM BLOOD ___ PTT-35.1* ___ ___ 11: 45AM BLOOD ALT-30 AST-28 AlkPhos-132* Amylase-22 TotBili-0.2 ___ 07: 25AM BLOOD HBsAg-NEGATIVE ___ 07: 25AM BLOOD HIV Ab-NEGATIVE ___ 07: 25AM BLOOD HCV Ab-NEGATIVE ___ 11: 45AM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG ___ GC/CT: negative RPR: negative cyst fluid culture: pending ___ PUS 1. Enlargement of the left ovary with hyperemia and dilation of the adherent left fallopian tube. Small cul-de-sac collection. These findings in accordance with CT raise suspicion for tubo-ovarian abscess. Followup ultrasound is recommended post- treatment. 2. Mild left hydronephrosis, which likely occurs secondary to mild compression at the left distal ureter from the left adnexal process. ___ CT 1. Large complex cystic left adnexal lesion which most likely represents tubo- ovarian abscess. Correlation with ultrasound is recommended. Followup imaging (US) is advised following treatment. <MEDICATIONS ON ADMISSION> None <DISCHARGE MEDICATIONS> 1. Flagyl 500 mg Tablet Sig: One (1) Tablet PO twice a day for 2 weeks. Disp: *28 Tablet(s)* Refills: *0* 2. Doxycycline Hyclate 100 mg Tablet Sig: One (1) Tablet PO twice a day for 2 weeks. Disp: *28 Tablet(s)* Refills: *0* <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> tuboovarian absess <DISCHARGE CONDITION> Stable <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Call your physician if you experience severe abdominal pain, nausea, vomitting, fevers, or any other concerning symptoms. Please use protection while having sexual intercourse.
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___ G0 with 10 days of LLQ pain and fevers, without PMH or PGYNHx, with fullness in the L adnexa and evidence of a L adnexal cystic lesion seen on CT, and cul-de-sac collection on US admitted to the inpatient gynecology service. Patient's CRP was elevated at 155. The likely diagnosis is PID with tuboovarian abscess. Infected endometrioma may also be in the differential although the patient denies any history of dysmenorrhea. Patient was started on IV ampicillin, gentamicin, and flagyl for empiric for PID with ___. Patient underwent US-guided drainage of left cyst ___. Approximately 10 cc of clear fluid were aspirated and sent for culture and gram stain. As the aspiration did not reveal pus, the procedure was terminated. The procedure was uncomplicated. At the time of this report, the final cyst fluid culture result is pending. The patient remained afebrile throughout the hospitalization. Sexually transmitted infection panel was pan negative. In light of elevated CRP, patient was discharged home with a 2 week Doxycycline and Flagyl. She will follow up in ___ clinic and repeat imaging in ___ weeks.
| 1,047 | 262 |
10033760-DS-7
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___ <CHIEF COMPLAINT> symptomatic fibroid uterus, right ovarian cyst <MAJOR SURGICAL OR INVASIVE PROCEDURE> abdominal myomectomy, right oophorectomy <HISTORY OF PRESENT ILLNESS> This is a ___ gravida 1, para 1, who is status post imaging studies that show a large fibroid uterus. She is status post endometrial biopsy on ___, which showed secretory endometrium. She presents today for further discussion of treatment options. The patient has done much research and presents today requesting multiple myomectomy with the knowledge that because of the size and multiplicity of her uterine fibroid, she could end up with a supracervical hysterectomy. She also has a right ovarian cyst and is requesting right ovarian cystectomy, but understands that she might end up with a right oophorectomy. <PAST MEDICAL HISTORY> OB/GYN HISTORY: Menarche at 12. She cycles monthly, last menstrual period she believes was ___. She notes her menses are heavy with clots. The patient's last Pap smear is unknown. Therefore, Pap will be updated today. She denies any history of abnormal Paps. She is not sexually active. She has used oral contraceptive pills in her remote past for approximately a year. She does have a history of cyst in her ovaries and clearly as stated above. She has had one pregnancy, vaginal delivery, ___, no complications. She denies ever having sexually transmitted infections. PAST MEDICAL HISTORY: Childhood anemia, cholecystitis, overactive bladder, PTSD, hemorrhoids, intermittent unusual foot pains. OPERATIVE HISTORY: In the ___, she had appendix out in ___ as a child and in the 1990s, gallbladder out here at the ___. <SOCIAL HISTORY> ___ <FAMILY HISTORY> FAMILY HISTORY: Negative for any female cancers. <PHYSICAL EXAM> INITIAL PHYSICAL EXAMINATION: GENERAL: This is a well-developed, well-nourished woman in no apparent distress. VITAL SIGNS: Blood pressure 116/62, weight 183. ABDOMEN: Soft, nondistended, palpable mass approximately 18 cm in maximum vertical dimension and there certainly was a softer palpable mass to the patient's right consistent with that described dumbbell-shaped cystic structure on ultrasound. PELVIC: Normal female external genitalia. Bartholin, urethral, and Skene's glands were normal. The vaginal vault did have a watery discharge. Cultures were done for BV and yeast. Cervix without cervical motion tenderness. Pap smear was updated including HPV testing. Uterus approximately 18 cm in maximum vertical dimension with again that softer larger 12 cm cystic-appearing mass in the mid lateral right aspect of the patient's abdomen. ON DAY OF DISCHARGE GEN: NAD CV: RRR LUNGS: CTABL ABD: NT/ND INCISIONS C/D/I EXT: WNL <MEDICATIONS ON ADMISSION> MVI <DISCHARGE MEDICATIONS> 1. Docusate Sodium 100 mg PO BID RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice a day Disp #*50 Capsule Refills: *0 2. Ibuprofen 600 mg PO Q6H: PRN Pain take with food RX *ibuprofen 600 mg 1 tablet(s) by mouth q6h: prn Disp #*80 Tablet Refills: *0 3. Oxycodone-Acetaminophen (5mg-325mg) ___ TAB PO Q4H: PRN Pain DO NOT: drive or take with alcohol/sedatives *contains tylenol RX *oxycodone-acetaminophen 5 mg-325 mg ___ tablet(s) by mouth q4h: prn Disp #*40 Tablet Refills: *0 <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> fibroid uterus, dermoid cyst (final pathology pending) <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Dear Ms. ___, You were admitted to the gynecology service after your procedure. You have recovered well and the team believes you are ready to be discharged home. Please call Dr. ___ office with any questions or concerns. Please follow the instructions below. General instructions: * Take your medications as prescribed. * Do not drive while taking narcotics. * Take a stool softener such as colace while taking narcotics to prevent constipation. * Do not combine narcotic and sedative medications or alcohol. * Do not take more than 4000mg acetaminophen (APAP) in 24 hrs. * No strenuous activity until your post-op appointment. * Nothing in the vagina (no tampons, no douching, no sex) for 6 weeks. * No heavy lifting of objects >10 lbs for 6 weeks. * You may eat a regular diet. * You may walk up and down stairs. Incision care: * You may shower and allow soapy water to run over incision; no scrubbing of incision. No bath tubs for 6 weeks. * If you have steri-strips, leave them on. They will fall off on their own or be removed during your followup visit. To reach medical records to get the records from this hospitalization sent to your doctor at home, call ___-
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On ___, Ms. ___ was admitted to the gynecology service after undergoing abdominal myomectomy and right oophorectomy. 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 ibuprofen and percocet. 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.
| 1,217 | 152 |
10037313-DS-22
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___ <CHIEF COMPLAINT> fibroid uterus <MAJOR SURGICAL OR INVASIVE PROCEDURE> Abdominal multiple myomectomy <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> ___ 10: 00AM WBC-3.0* RBC-3.59* HGB-10.6* HCT-34.5 MCV-96# MCH-29.5# MCHC-30.7* RDW-16.1* RDWSD-48.3* ___ 10: 00AM WBC-3.0* RBC-3.59* HGB-10.6* HCT-34.5 MCV-96# MCH-29.5# MCHC-30.7* RDW-16.1* RDWSD-48.3* <MEDICATIONS ON ADMISSION> Norethindrone 5mg QD <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 [Colace] 100 mg 1 capsule(s) by mouth twice daily Disp #*60 Capsule Refills: *1 3. Ibuprofen 600 mg PO Q6H: PRN Pain - Mild 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 Do not drink alcohol or drive while taking this medication. RX *oxycodone 5 mg ___ tablet(s) by mouth every 4 hours Disp #*50 Tablet Refills: *0 <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> Fibroid uterus <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Dear Ms. ___ , You were admitted to the gynecology service after your procedure. You have recovered well and the team believes you are ready to be discharged home. Please call Dr. ___ office with any questions or concerns. Please follow the instructions below. General instructions: * Take your medications as prescribed. * Do not drive while taking narcotics. * Take a stool softener such as colace while taking narcotics to prevent constipation. * Do not combine narcotic and sedative medications or alcohol. * Do not take more than 4000mg acetaminophen (APAP) in 24 hrs. * No strenuous activity until your post-op appointment. * Nothing in the vagina (no tampons, no douching, no sex) for 6 weeks. * No heavy lifting of objects >10 lbs for 6 weeks. * You may eat a regular diet. * You may walk up and down stairs. Incision care: * You may shower and allow soapy water to run over incision; no scrubbing of incision. No tub baths for 6 weeks. * If you have steri-strips, leave them on. They will fall off on their own or be removed during your followup visit. Call your doctor for: * fever > 100.4F * severe abdominal pain * difficulty urinating * vaginal bleeding requiring >1 pad/hr * abnormal vaginal discharge * redness or drainage from incision * nausea/vomiting where you are unable to keep down fluids/food or your medication To reach medical records to get the records from this hospitalization sent to your doctor at home, call ___. Constipation: * Drink ___ liters of water every day. * Incorporate 20 to 35 grams of fiber into your daily diet to maintain normal bowel function. Examples of high fiber foods include: Whole grain breads, Bran cereal, Prune juice, Fresh fruits and vegetables, Dried fruits such as dried apricots and prunes, Legumes, Nuts/seeds. * Take Colace stool softener ___ times daily. * Use Dulcolax suppository daily as needed. * Take Miralax laxative powder daily as needed. * Stop constipation medications if you are having loose stools or diarrhea.
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On ___, Ms. ___ was admitted to the gynecology service after undergoing and abdominal multiple myomectomy. 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 oxycodone/acetaminophen/ibuprofen(pain meds). By post-operative day 1, she was tolerating a regular diet, voiding spontaneously, ambulating independently, and pain was controlled with oral medications. She was then discharged home in stable condition with outpatient follow-up scheduled.
| 1,039 | 156 |
10039110-DS-15
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Diflucan <ATTENDING> ___ <CHIEF COMPLAINT> Vaginal bleeding <MAJOR SURGICAL OR INVASIVE PROCEDURE> none <HISTORY OF PRESENT ILLNESS> Patient is a ___ y/o G6P2 with a history of known fibroid uterus, history of anemia, history of PE on Eliquis (___), who presents with vaginal bleeding. LMP started ___ - has been much heavier than her prior periods. Changing "more than one pad" per hour, having dizziness, palpitations, SOB as well. Mild cramping. She is followed by Dr. ___ office for her fibroid uterus. Started Lupron (test dose ___, first dose ___ - 11.25 mg with plan for Q3 month injections). Had been advised to get ferraheme injections for anemia, baseline Hct ___, but did not keep appointments. She underwent an endometrial biopsy in ___, which returned as proliferative endometrium and benign endocervix. Patient states she has discussed hysterectomy with Dr. ___ but was "waiting for her blood counts to come up." <PAST MEDICAL HISTORY> OB History: - TAB x 4 - LTCS x 2 GYN History: - LMP ___ - last pap smear ___ NILM HPV- - fibroid uterus, as per above PMH: - anemia - "fatty liver" - PE (___) on Eliquis Surgical History: - (___) prim LTCS - (___) open MMY - (___) rpt LTCS - (___) laparoscopic hiatal hernia repair, Roux-En-Y, LOA <SOCIAL HISTORY> ___ <FAMILY HISTORY> No history of ovarian, uterine, breast, or colon cancer. <PHYSICAL EXAM> Vitals: Stable and within normal limits General: NAD, comfortable CV: RRR Lungs: CTAB Abdomen: soft, non-distended, non-tender, uterus palpable ~5 cm above umbilicus GU: pad with minimal spotting Extremities: no edema, no TTP, pneumoboots in place bilaterally <PERTINENT RESULTS> ___ 05: 00AM BLOOD WBC-8.1 RBC-4.42 Hgb-7.1* Hct-26.1* MCV-59* MCH-16.1* MCHC-27.2* RDW-22.2* RDWSD-43.2 Plt ___ ___ 11: 02AM BLOOD WBC-6.3 RBC-3.47* Hgb-5.6* Hct-20.5* MCV-59* MCH-16.1* MCHC-27.3* RDW-21.9* RDWSD-43.4 Plt ___ ___ 12: 35AM BLOOD WBC-6.0 RBC-3.99 Hgb-8.4* Hct-27.6* MCV-69* MCH-21.1* MCHC-30.4* RDW-29.4* RDWSD-67.8* Plt ___ ___ 05: 00AM BLOOD Neuts-66.9 Lymphs-18.9* Monos-7.6 Eos-5.3 Baso-0.9 Im ___ AbsNeut-5.45 AbsLymp-1.54 AbsMono-0.62 AbsEos-0.43 AbsBaso-0.07 ___ 07: 25AM BLOOD Neuts-60.0 ___ Monos-9.7 Eos-4.9 Baso-0.5 Im ___ AbsNeut-3.29 AbsLymp-1.34 AbsMono-0.53 AbsEos-0.27 AbsBaso-0.03 ___ 05: 00AM BLOOD Glucose-74 UreaN-13 Creat-1.1 Na-139 K-4.1 Cl-107 HCO3-20* AnGap-12 <MEDICATIONS ON ADMISSION> Apixaban 5 mg PO BID <DISCHARGE MEDICATIONS> 1. Acetaminophen ___ mg PO Q6H: PRN Pain - Mild/Fever 2. MedroxyPROGESTERone Acetate 10 mg PO BID RX *medroxyprogesterone [Provera] 10 mg 1 tablet(s) by mouth twice a day Disp #*20 Tablet Refills: *0 3. Apixaban 5 mg PO BID <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> Vaginal bleeding secondary to known 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 to manage your vaginal bleeding. You have recovered well and the team believes you are ready to be discharged home. Please call Dr. ___ office with any questions or concerns. Please follow the instructions below. General instructions: * Take your medications as prescribed. * You may eat a regular diet. 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 * chest pain, headache, or difficulty breathing To reach medical records to get the records from this hospitalization sent to your doctor at home, call ___.
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On ___, Ms. ___ was admitted to the gynecology service after presenting with vaginal bleeding secondary to known fibroid uterus, with possible additional Lupron effect. Her Hct on initial presentation was 20.5. On HD#1 she received 2 units packed RBCs with a rise in her Hct to 23.7. She was also started on Provera 10 mg daily. ___ was consulted and planned for uterine artery embolization. On HD#2 her Hct was 22.1 and she received an additional two units packed RBCs with appropriate response of her hematocrit to 27.6 and subjective improvement in her symptoms. Her Provera was also increased to 10 mg twice daily. By HD #3, she had minimal ongoing vaginal bleeding and was overall feeling better. She elected to defer UAE during this admission and requested to be discharged home. Her foley catheter was removed and she voided spontaneously. She had minimal pain, was ambulating independently, and continued on regular diet. She was discharged home in stable condition with outpatient follow-up scheduled.
| 1,233 | 230 |
10039110-DS-16
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___ <CHIEF COMPLAINT> Symptomatic fibroid uterus <MAJOR SURGICAL OR INVASIVE PROCEDURE> Total abdominal hysterectomy, Bilateral salpingectomy <HISTORY OF PRESENT ILLNESS> ___ is a ___ gravida 7 ___ who returns to discuss further future hysterectomy and bilateral salpingectomy. On ___, endometrial biopsy showed proliferative endometrium and benign endocervix. She has a history of an enlarged uterus, excessive uterine bleeding. And chronic/acute blood loss anemia for which she has received IV iron therapy. In addition, in efforts to decrease her uterine fibroid burden and decrease her excessive bleeding she has been on IM Lupron therapy. Since initiating Lupron therapy she has had no further vaginal bleeding. She will get a 3-month dose today. She has a history of thrombosis/pulmonary embolism and has been treated with Eliquis. She has an appointment with Dr. ___ ___, heme-onc for recommendations in regard to perioperative anticoagulation therapy. <PAST MEDICAL HISTORY> OB History: - TAB x 4 - LTCS x 2 GYN History: - LMP ___ - last pap smear ___ NILM HPV- - fibroid uterus, as per above PMH: - anemia - "fatty liver" - PE (___) on Eliquis Surgical History: - (___) prim LTCS - (___) open MMY - (___) rpt LTCS - (___) laparoscopic hiatal hernia repair, Roux-En-Y, LOA <SOCIAL HISTORY> ___ <FAMILY HISTORY> No history of ovarian, uterine, breast, or colon cancer. <PHYSICAL EXAM> On day of discharge: <PERTINENT RESULTS> ___ 10: 25AM BLOOD WBC-7.1 RBC-5.03 Hgb-11.0* Hct-36.1 MCV-72* MCH-21.9* MCHC-30.5* RDW-16.6* RDWSD-42.7 Plt ___ <MEDICATIONS ON ADMISSION> Apixaban 2.5mg BID Leuprolide <DISCHARGE MEDICATIONS> 1. Acetaminophen ___ mg PO Q6H: PRN Pain - Mild/Fever Do not exceed 4000mg in 24 hrs RX *acetaminophen 500 mg 2 tablet(s) by mouth every six (6) hours Disp #*50 Tablet Refills: *2 2. Apixaban 2.5 mg PO BID RX *apixaban [Eliquis] 2.5 mg 1 tablet(s) by mouth Two times per day Disp #*56 Tablet Refills: *2 3. Docusate Sodium 100 mg PO BID Hold for loose stools RX *docusate sodium 100 mg 1 capsule(s) by mouth Twice per day Disp #*60 Capsule Refills: *0 4. OxyCODONE (Immediate Release) 5 mg PO Q4H: PRN Pain - Moderate ___ cause sedation. Do not drink or drive. RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours Disp #*15 Tablet Refills: *0 <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> Fibroid uterus <DISCHARGE CONDITION> Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Ms. ___ ___ were admitted to the gynecology service after your procedure. ___ have recovered well and the team believes ___ are ready to be discharged home. Please call Dr. ___ office with any questions or concerns. Please follow the instructions below. General instructions: * Take your medications as prescribed. * Do not drive while taking opioids (e.g. oxycodone, hydromorphone) * Take a stool softener such as colace while taking opioids to prevent constipation. * Do not combine opioid and sedative medications or alcohol. * Do not take more than 4000mg acetaminophen (APAP) in 24 hrs. * No strenuous activity until your post-op appointment. * Nothing in the vagina (no tampons, no douching, no sex) for 6 weeks. * No heavy lifting of objects >10 lbs for 6 weeks. * ___ may eat a regular diet. * ___ may walk up and down stairs. Incision care: * ___ may shower and allow soapy water to run over incision; no scrubbing of incision. No tub baths for 6 weeks. * Leave the steri-strips in place. They will fall off on their own. If they have not fallen off by 7 days post-op, ___ may remove them. * If ___ 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 ___ 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 ___ are having loose stools or diarrhea. To reach medical records to get the records from this hospitalization sent to your doctor at home, call ___.
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On ___, Ms. ___ was admitted to the gynecology service after undergoing the procedures listed below. 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 a TAP block. She was transitioned to lovenox 12 hours post-operatively given her history of provoked PE. On post-operative day 1, her urine output was adequate, so her foley was removed, and she voided spontaneously. Her diet was advanced without difficulty, and she was transitioned to PO oxycodone, tylenol. By post-operative day 2 she was tolerating a regular diet, voiding spontaneously, ambulating independently, and pain was controlled with oral medications. She was then discharged home in stable condition with outpatient follow-up scheduled.
| 1,304 | 172 |
10040768-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> Dilation and Curettage <HISTORY OF PRESENT ILLNESS> Ms. ___ is a ___ s/p TAB at 16 weeks on ___ who presents with heavy vaginal bleeding. She reports that she has had daily spotting since she had the TAB. However, she was a party around midnight and had heavy bleeding more than 3 cups into the toilet followed by passage of clots. She denies any fevers, chills, abdominal pain, chest pain or shortness of breath. She had complained of lightheaded on presentation to the ED but feels better now. Denies nausea, vomiting or abnormal vaginal discharge. Denies intercourse since procedure and has not been on birth control. <PAST MEDICAL HISTORY> Gyn Hx: - Unknown LMP - remote h/o genital herpes - last Pap in system ___ wnl, due for follow up - current contraception: condoms - past contraception: OCPs, depoprovera, condoms, reports spotting with all past contraceptives. OBHx: G1: SVD 8# term female (___) G2: pLTCS twins female (___) G3-G8: TAB (D+C) PAST MEDICAL HISTORY: pancreatitis, recurrent UTIs PAST SURGICAL HISTORY: TAB x 6 with D&C's <SOCIAL HISTORY> ___ <FAMILY HISTORY> non-contributory <PHYSICAL EXAM> Physical Examination Upon Presentation Time Pain Temp HR BP RR Pox Glucose + Triage 00: 37 5 98.8 108 156/96 18 99% ra Today 02: 37 0 86 108/62 18 100% RA Today 03: 21 87 121/67 18 99% RA No acute distress Abdomen soft, non-tender and non-distended Pelvic exam: On insertion of speculum, cervix is visualized and appears parous, vaginal vault was cleaned out with 1 scopette and there was no active bleeding. There was no CMT and no uterine tenderness or adnexal tenderness to palpation. Ext non-tender and non-distended. Physical Examination Upon Discharge Vital signs stable Well appearing, no acute distress Abdomen soft, nontender Vaginal bleeding minimal <PERTINENT RESULTS> ___ 12: 55AM PLT COUNT-327# ___ 12: 55AM NEUTS-62.0 ___ MONOS-4.2 EOS-3.2 BASOS-0.5 ___ 12: 55AM WBC-8.1 RBC-3.42* HGB-9.5* HCT-30.6* MCV-90 MCH-27.7# MCHC-30.9*# RDW-14.1 ___ 12: 55AM HCG-10 ___ 12: 55AM estGFR-Using this ___ 12: 55AM GLUCOSE-88 UREA N-10 CREAT-0.8 SODIUM-139 POTASSIUM-4.0 CHLORIDE-104 TOTAL CO2-23 ANION GAP-16 Intraoperative Findings: 1. Exam under anesthesia: Small anteverted uterus. Cervix 1 cm dilated. 2. Products of conception and clot. <MEDICATIONS ON ADMISSION> denies <DISCHARGE MEDICATIONS> 1. Ibuprofen 600 mg PO Q6H: PRN pain RX *ibuprofen 600 mg 1 tablet(s) by mouth every 6 hours Disp #*30 Tablet Refills: *0 <DISCHARGE DISPOSITION> Home <DISCHARGE DIAGNOSIS> Retained products of conception <DISCHARGE CONDITION> Activity Status: Ambulatory - Independent. Level of Consciousness: Alert and interactive. Mental Status: Clear and coherent. <FOLLOWUP INSTRUCTIONS> ___ <DISCHARGE INSTRUCTIONS> Dear Ms. ___, You were admitted to the gynecology service after your procedure. You have recovered well and the team believes you are ready to be discharged home. Please call the office with any questions or concerns. Please follow the instructions below. General instructions: * Take 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. 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 overnight on ___ to the gynecology service for retained products of conception diagnosed by pelvic ultrasound in the setting of vaginal bleeding following an elective termination on ___. Her hematocrit was 30.6 on presentation. She was taken to the operating room for a dilation and curretage. Her operative course was uncomplicated. Please see report for full details. She recovered well and was discharged home later that day in stable condition with follow up scheduled with Dr. ___ on ___.
| 1,051 | 101 |
10041339-DS-17
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> Sulfa (Sulfonamide Antibiotics) <ATTENDING> ___. <CHIEF COMPLAINT> pprom <MAJOR SURGICAL OR INVASIVE PROCEDURE> exam under anesthesia s/p vaginal delivery, bakri placed postpartum, removed <PHYSICAL EXAM> On discharge: Vitals: 24 HR Data (last updated ___ @ 018) Temp: 97.5 (Tm 98.1), BP: 101/67 (97-131/61-77), HR: 99 (94-99), RR: 18, O2 sat: 99% (98-99), O2 delivery: RA Fluid Balance (last updated ___ @ 020) Last 8 hours Total cumulative -900ml IN: Total 0ml OUT: Total 900ml, Urine Amt 900ml Last 24 hours Total cumulative -2600ml IN: Total 1000ml, PO Amt 1000ml OUT: Total 3600ml, Urine Amt 3600ml General: NAD, A&Ox3 CV: RRR Lungs: No respiratory distress Abd: soft, overall nontender excepting some mild tenderness over umbilicus, fundus firm below umbilicus Lochia: minimal Extremities: no calf tenderness, no edema <PERTINENT RESULTS> ___ 03: 05AM BLOOD WBC-17.2* RBC-2.59* Hgb-8.6* Hct-25.2* MCV-97 MCH-33.2* MCHC-34.1 RDW-15.1 RDWSD-52.8* Plt Ct-81* ___ 01: 18AM BLOOD WBC-16.9* RBC-2.67* Hgb-9.0* Hct-25.3* MCV-95 MCH-33.7* MCHC-35.6 RDW-14.6 RDWSD-50.4* Plt Ct-83* ___ 08: 45PM BLOOD WBC-16.2* RBC-2.54* Hgb-8.9* Hct-26.7* MCV-105* MCH-35.0* MCHC-33.3 RDW-14.1 RDWSD-53.8* Plt ___ ___ 03: 10PM BLOOD WBC-10.1* RBC-3.07* Hgb-10.7* Hct-31.0* MCV-101* MCH-34.9* MCHC-34.5 RDW-14.2 RDWSD-52.0* Plt ___ ___ 10: 40AM BLOOD WBC-8.2 RBC-2.82* Hgb-9.9* Hct-29.3* MCV-104* MCH-35.1* MCHC-33.8 RDW-14.2 RDWSD-53.3* Plt ___ ___ 12: 30PM BLOOD WBC-11.2* RBC-2.98* Hgb-10.5* Hct-30.4* MCV-102* MCH-35.2* MCHC-34.5 RDW-13.8 RDWSD-50.6* Plt ___ ___ 01: 18AM BLOOD Glucose-92 UreaN-9 Creat-0.4 Na-133* K-3.7 Cl-107 HCO3-17* AnGap-9* <DISCHARGE INSTRUCTIONS> pelvic rest for 6 weeks, rest
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ANTEPARTUM She was admitted to antepartum after it was confirmed that her amniotic membranes ruptured. She was given latency antibiotics, underwent a NICU consult, and received betamethasone. She remained stable until 34 weeks gestational age and underwent induction of labor. POST PARTUM On ___, patient had a spontaneous vaginal delivery. This was complicated by post partum hemorrhage and chorioamnionitis. Regarding her postpartum hemorrhage, her total estimated blood loss was 2400mL due to uterine atony and a posterior cervical laceration. She necessitated an OR takeback for improved visualization and repair of the cervical laceration. She received pitocin, cytotec, methergine, TXA. A Bakri balloon balloon for 240mL was placed as well as vaginal packing. She received 2 units of packed RBCs. Her hematocrit was obtained and noted to be 25.3 (___) with platelets of 83. Her fibrinogen was 180. Her INR was 1.3 over two measurements (___). Her vitals remained stable and her vaginal packing and bakri balloon were removed on ___. Regarding her chorioamnionitis, patient received 2g of ancef in the OR. She had a fever of approximately ___ on ___ at 2145. She received ampicillin and gentamicin for 24 hours first afebrile ___ afebrile 0300 ___. For her GDMA1, patient's fingersticks were not followed. On post partum day 3, ___, patient had stable vitals and accomplished all her post partum milestones. Her bleeding was stable and she was thus discharged to home in stable condition. Discharge Medications: 1. Acetaminophen ___ mg PO Q6H:PRN Pain - Mild/Fever 2. Ibuprofen 600 mg PO Q6H:PRN Pain - Mild/Fever NOT relieved by Acetaminophen RX *ibuprofen 600 mg 1 tablet(s) by mouth every six (6) hours Disp #*40 Tablet Refills:*0 3. Docusate Sodium 100 mg PO BID 4. Levothyroxine Sodium 50 mcg PO 5X/WEEK (___) 5. Levothyroxine Sodium 25 mcg PO 2X/WEEK (___) Discharge Disposition: Home Discharge Diagnosis: s/p vaginal delivery postpartum hemorrhage Discharge Condition: stable Followup Instructions: ___
| 813 | 541 |
10041958-DS-6
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<SEX> F <SERVICE> OBSTETRICS/GYNECOLOGY <ALLERGIES> No Known Allergies / Adverse Drug Reactions <ATTENDING> ___ <CHIEF COMPLAINT> Symptomatic Fibroid Uterus <MAJOR SURGICAL OR INVASIVE PROCEDURE> Total abdominal hysterectomy Bilateral salpingectomy <HISTORY OF PRESENT ILLNESS> Ms. ___ is a ___ yo G4, P3, Term3, Preterm0, Abt1, Sab0, Tab1, Ect0, Live3. Patient's last menstrual period was ___. She presents for pre-op visit for planned surgery, Total Abdominal Hysterectomy at ___ on ___ for large fibroid uterus. Progressively increasing myoma causing abdominal discomfort, urinary frequency. Pt has been referred by Dr ___ hysterectomy. <PAST MEDICAL HISTORY> PMH: migraine, low back pain, iron deficiency anemia, H pylori, colonic adenoma, fibroid, elevated A1c, DJD of knee PSH: laparoscopic tubal ligation, excision vaginal cyst, D&C, LEEP ObHx: G4P3, Term#, Preterm0, Abt1, Sab0, Tab1, Ect0, Live 3. GynHx: fibroid Uterus <SOCIAL HISTORY> ___ <FAMILY HISTORY> Father with DMT2 and hypertension Mother with breast cancer and hypertension <PHYSICAL EXAM> Discharge physical exam Vitals: VSS Gen: NAD, A&O x 3 CV: RRR Resp: no acute respiratory distress Abd: soft, appropriately tender, nondistended, no rebound/guarding, incision c/d/i Ext: no TTP <PERTINENT RESULTS> None. **Pathology Pending <MEDICATIONS ON ADMISSION> Ibuprofen <DISCHARGE MEDICATIONS> 1. Acetaminophen ___ mg PO Q6H: PRN pain Do not exceed 4,000mg in 24 hours RX *acetaminophen 500 mg ___ tablet(s) by mouth q6h prn Disp #*50 Tablet Refills: *2 2. Docusate Sodium 100 mg PO BID Take while taking pain meds RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day Disp #*50 Capsule Refills: *2 3. OxycoDONE (Immediate Release) ___ mg PO Q4H: PRN pain Do not drive while taking medication RX *oxycodone 5 mg ___ tablet(s) by mouth q4h prn Disp #*30 Tablet Refills: *0 4. Ibuprofen 600 mg PO Q6H: PRN pain Take with food RX *ibuprofen 600 mg 1 tablet(s) by mouth q6h prn Disp #*50 Tablet Refills: *0 <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. To reach medical records to get the records from this hospitalization sent to your doctor at home, call ___.
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On ___, Ms. ___ was admitted to the gynecology service after undergoing a total abdominal hysterectomy, bilateral salpingectomy for symptomatic fibroid uterus. Please see the operative report for full details. Her post-operative course was uncomplicated. Immediately post-op, her pain was controlled with IV Dilaudid and toradol. On post-operative day 1, her urine output was adequate so her foley was removed and she voided spontaneously. Her diet was advanced without difficulty and she was transitioned to PO oxycodone, ibuprofen, and acetaminophen. By post-operative day 2, she was tolerating a regular diet, voiding spontaneously, ambulating independently, and pain was controlled with oral medications. She was then discharged home in stable condition with outpatient follow-up scheduled.
| 966 | 165 |
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