212512774 WGH
6218589
29021
9923207
10/31/2004 12:00:00 AM
OB Discharge Summary
Signed
DIS
Report Status :
Signed OB EMR L and D
DISCHARGE SUMMARY
NAME :
RIASHWAN BERLNI VALLEY
UNIT NUMBER :
130-93-91
ADMISSION DATE :
20041031
DISCHARGE DATE :
20041103
PRINCIPAL DISCHARGE DIAGNOSIS :
Vaginal Delivery With Second Degree Laceration
ASSOCIATED DIAGNOSES :
Abnormal Laboratory Result ; Abnormal Pap Test ; Monilial Vaginitis
PRINCIPAL PROCEDURE OR OPERATION :
Spontaneous Vertex Vaginal Delivery
ASSOCIATED PROCEDURES OR OPERATIONS :
POSTPARTUM DIAGNOSTIC PROCEDURES :
None
POSTPARTUM THERAPEUTIC PROCEDURES :
None
OTHER POSTPARTUM THERAPIES :
Routine Post Partum Care
HISTORY AND REASON FOR HOSPITALIZATION :
Premature Rupture Of Membranes
PHYSICAL EXAMINATION :
HEIGHT 63 HEENT NORMAL MOUTH NORMAL NECK NORMAL BREASTS NORMAL No masses NIPPLES NORMAL CHEST NORMAL CTA bilat , neg wheezing COR NORMAL NSR , no murmur ABDOMEN Gravid , vtx .
EFW = 7# .
FHTs 140s w/ reactivity .
Mild irreg. ctx .
EXTREM NORMAL SKIN NORMAL NODES NORMAL VULVA NORMAL VAGINA Leaking copious amounts clear fluid .
Fluid amnioswab and fern positive .
SSE and digital exam deferred CERVIX digital exam deferred at time of admission OS NORMAL see above ADNEXAE NORMAL non-palp d / t advanced gest UTERUS Gravid , vtx .
EFW = 7# .
FHTs 140s w/ reactivity .
Ctx q 6 ' .
UTERINE SIZE IN WEEKS 38
HOSPITAL COURSE ( include complications if any ) :
This 27 year old Gravida 1 Para 0000 was admitted to the Life Valley Medical Center Obstetrical service on 10/31/2004 at 08:45 pm for the indication ( s ) :
premature rupture of membranes .
She delivered a 3235 gram male infant on 11/01/2004 at 09:31 am with apgar scores of 9 and 9 at one and five minutes respectively at 39.0 weeks gestation via spontaneous vertex vaginal delivery .
During her labor she encountered the following complication ( s ) :
none .
During her delivery she encountered the following complication ( s ) :
none .
Postpartum she encountered the following complication ( s ) :
none .
She was discharged on 11/03/2004 at 11:18 am in good condition .
DISCHARGE ORDERS ( medications instructions to patient , follow-up care ) :
DISCHARGE ACTIVITY :
No Restrictions
DISCHARGE DIET :
No Restrictions
POSTPARTUM DISPOSITION :
Home With Self-Care ( Routine Discharge )
POSTPARTUM CARE SITE :
La Community Hospital
POSTPARTUM RETURN APPOINTMENT ( DAYS ) :
42
BREAST FEEDING AT DISCHARGE :
Yes
POSTPARTUM RH IMMUNE GLOBULIN :
Not Indicated
POSTPARTUM MEASLES / MUMPS / RUBELLA VACCINE :
Not Indicated
MEDICATION ( S ) ON DISCHARGE :
Multivitamins And Folate
Electronically Signed :
Fyfe , Lan S 11/03/2004 11:19:27 AM