Stress incontinence female Cystocele midline Urethral hypermobility Unspecified essential hypertension Unspecified acquired hypothyroidism Polymyalgia rheumatica Other and unspecified hyperlipidemia Long-term (current) use of aspirin Long-term (current) use of steroids
 
Name:  ___                  Unit No:   ___
 
Admission Date:  ___              Discharge Date:   ___
 
Date of Birth:  ___             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
 
Brief Hospital Course:
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.

 
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.
 
Followup Instructions:
___

{'vaginal spotting': ['Cystocele'], 'stress urinary incontinence': ['Stress incontinence', 'Urethral hypermobility'], 'urethral meatus': [], 'vaginal atrophy': ['Cystocele'], 'urinary retention': ['Stress incontinence', 'Urethral hypermobility'], 'bladder prolapse': ['Cystocele']}