DATE OF ADMISSION: MM/DD/YYYY
DATE OF DISCHARGE: MM/DD/YYYY
ADMISSION DIAGNOSES:
1. Pelvic organ prolapse, specifically cystocele.
2. Hypertension.
3. Diabetes.
POSTOPERATIVE DIAGNOSES:
1. Pelvic organ prolapse, specifically cystocele.
2. Hypertension.
3. Diabetes.
HISTORY: The patient is a (XX)-year-old G5, P 4-0-1-4 with a history of a cystocele who presented for an anterior repair with Prolift. The patient also has a history of an overactive bladder with urge incontinence.
PAST MEDICAL HISTORY: Significant for diabetes, high cholesterol, and hypertension.
PAST SURGICAL HISTORY: Bilateral tubal ligation.
MEDICATIONS: Glucovance, Avandia, simvastatin, Benicar, Caltrate Plus D, and iron.
ALLERGIES: NKDA.
FAMILY HISTORY: Noncontributory.
SOCIAL HISTORY: No alcohol, drugs or tobacco.
PHYSICAL EXAMINATION: Vital Signs: On admission, she is 5 feet 3 inches tall, 155 pounds. Her blood pressure is 120/68, pulse 86, respirations 20. Her temperature is 97.6 degrees. She is alert and oriented x3. Head and neck exam is within normal limits. Heart: S1, S2, no murmurs. Chest: Clear to auscultation bilaterally. Abdomen: Benign, soft, nontender, nondistended. Positive bowel sounds. Neuromuscular exam is grossly intact. Extremities: Benign. No clubbing, cyanosis or edema.
LABORATORIES: On admission, her white blood cell count preoperatively was 5.8, her H&H 11.8 and 34.6 and platelets were 289,000.
HOSPITAL COURSE: The patient underwent an uncomplicated anterior repair with Prolift. Intraoperatively, the patient was noted to lose approximately 450 mL of blood. On postoperative day one, the patient was complaining of slight dizziness when she got up to go to the bathroom. CBC the night before, when the patient was slightly tachycardic, revealed an H&H of 7.8 and 23.8. The following morning, when the patient was complaining of slight dizziness, when she got up to go to the bathroom, her H&H was noted to be 6.6 and 20.2. She also complained of some congestion and difficulty with deep breaths secondary to increased mucus. The patient’s vital signs at that point, she was afebrile and her vitals were stable. Orthostatics were negative. Her fingerstick glucose was 92 on postoperative day one. A chest x-ray was ordered due to her congestion, which was essentially benign, except for evidence of atherosclerotic vascular disease, but there were no infiltrates. The decision was made, after discussing it with Dr. John Doe, to transfuse the patient 2 units of packed red blood cells due to her postoperative anemia to aid in healing, given the fact that she had a graft put in and she was a diabetic. On postoperative day one, the patient received 2 units of packed red blood cells over 4 hours each. She was premedicated with Lasix, Tylenol, and Benadryl. Her diabetes was controlled on a regular insulin sliding scale and her p.o. medications were added once she was tolerating a regular diet. She failed her voiding trial on postoperative day one. On postoperative day two, the patient was feeling much better. She was tolerating a regular diet. Her voiding trial was to be repeated on postoperative day two and her CBC, after her transfusion, revealed an H&H of 9.6 and 28.6 on postoperative day number two.
ASSESSMENT AND PLAN: The patient is a (XX)-year-old G5, P 4-0-1-4, status post anterior repair with Prolift and cystocele secondary to pelvic organ prolapse, and status post 2 units of packed red blood cells secondary to postoperative anemia. The patient is to undergo repeat voiding trial this morning, to ambulate, and she will likely be discharged home tomorrow to follow up with Dr. John Doe in the office in one week. She is to continue her Premarin cream at home.
