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PAST MEDICAL HISTORY: |
Status post artificial aortic valve implantation in summer of 2002 and is on chronic Coumadin therapy. COPD as described above, history of hypertension, and history of elevated cholesterol. |
PHYSICAL EXAMINATION: |
Heart tones regular with an easily audible mechanical click. Breath sounds are greatly diminished with rales and rhonchi over all lung fields. |
LABORATORY STUDIES: |
Sodium 139, potassium 4.5, BUN 42, and creatinine 1.7. Hemoglobin 10.7 and hematocrit 31.7. |
HOSPITAL COURSE: |
He was started on intravenous antibiotics, vigorous respiratory therapy, intravenous Solu-Medrol. The patient improved on this regimen. Chest x-ray did not show any CHF. The cortisone was tapered. The patient's oxygenation improved and he was able to be discharged home. |
DISCHARGE DIAGNOSES: |
Chronic obstructive pulmonary disease and acute asthmatic bronchitis. |
COMPLICATIONS: |
None. |
DISCHARGE CONDITION: |
Guarded. |
DISCHARGE PLAN: |
Prednisone 20 mg 3 times a day for 2 days, 2 times a day for 5 days and then one daily, Keflex 500 mg 3 times a day and to resume his other preadmission medication, can be given a pneumococcal vaccination before discharge. To follow up with me in the office in 4-5 days. |
ADMISSION DIAGNOSES: |
1. Severe menometrorrhagia unresponsive to medical therapy. |
2. Severe anemia. |
3. Fibroid uterus. |
DISCHARGE DIAGNOSES: |
1. Severe menometrorrhagia unresponsive to medical therapy. |
2. Severe anemia. |
3. Fibroid uterus. |
OPERATIONS PERFORMED: |
1. Hysteroscopy. |
2. Dilatation and curettage (D&C). |
3. Myomectomy. |
COMPLICATIONS: |
Large endometrial cavity fibroid requiring careful dissection and excision. |
BLOOD TRANSFUSIONS: |
Two units of packed red blood cells. |
INFECTION: |
None. |
SIGNIFICANT LAB AND X-RAY: |
Posttransfusion of the 2nd unit showed her hematocrit of 25, hemoglobin of 8.3. |
HOSPITAL COURSE AND TREATMENT: |
The patient was admitted to the surgical suite and taken to the operating room where a dilatation and curettage (D&C) was performed. Hysteroscopy revealed a large endometrial cavity fibroid. Careful shaving and excision of this fibroid was performed with removal of the fibroid. Hemostasis was noted completely at the end of this procedure. Postoperatively, the patient has done well. The patient was given a 2nd unit of packed red blood cells because of intraoperative blood loss. The patient is now ambulating without difficulty and tolerating her diet. The patient desires to go home. The patient is discharged to home. |
DISCHARGE CONDITION: |
Stable. |
DISCHARGE INSTRUCTIONS: |
Regular diet, bedrest for 1 week with slow return to normal activities over the ensuing 2 to 3 weeks, pelvic rest for 6 weeks. Vicodin tablets 1 tablet p.o. q.4-6 h. p.r.n. pain, multiple vitamin 1 tab p.o. daily, ferrous sulfate tablets 1 tablet p.o. daily. Ambulate with assistance at home only. The patient is to return to see Dr. X p.r.n. plus Tuesday, 6/16/2009 for further followup care. The patient was given full and complete postop and discharge instructions. All her questions were answered. |
DIAGNOSIS AT ADMISSION: |
Chronic obstructive pulmonary disease (COPD) exacerbation and acute bronchitis. |
DIAGNOSES AT DISCHARGE |
1. Chronic obstructive pulmonary disease exacerbation and acute bronchitis. |
2. Congestive heart failure. |
3. Atherosclerotic cardiovascular disease. |
4. Mild senile-type dementia. |
5. Hypothyroidism. |
6. Chronic oxygen dependent. |