424729395 DH
0011649
07013
908447
6/14/2001 12:00:00 AM
OB Discharge Summary
Signed
DIS
Report Status :
Signed OB EMR L and D
DISCHARGE SUMMARY
NAME :
XARAH RATIA SERVICE
UNIT NUMBER :
642-07-90
ADMISSION DATE :
20010614
DISCHARGE DATE :
20010616
PRINCIPAL DISCHARGE DIAGNOSIS :
Abnormal Fetal Heart Rate / Rhythm - Delivered
ASSOCIATED DIAGNOSES :
Abnormal Pap Test , history of
PRINCIPAL PROCEDURE OR OPERATION :
Vacuum Extraction
ASSOCIATED PROCEDURES OR OPERATIONS :
POSTPARTUM DIAGNOSTIC PROCEDURES :
None
POSTPARTUM THERAPEUTIC PROCEDURES :
None
OTHER POSTPARTUM THERAPIES :
Routine Post Partum Care
HISTORY AND REASON FOR HOSPITALIZATION :
Active Labor
PHYSICAL EXAMINATION :
HEIGHT 49 HEENT NORMAL MOUTH NORMAL NECK NORMAL BREASTS NORMAL NIPPLES NORMAL CHEST NORMAL COR NORMAL ABDOMEN NORMAL gravid , + FHR , NT EXTREM NORMAL SKIN NORMAL NODES NORMAL VULVA NORMAL VAGINA NORMAL CERVIX NORMAL 4-5/100% OS NORMAL closed , firm , -CMT ADNEXAE NORMAL UTERUS NORMAL term 7-7.5 # vtx UTERINE SIZE IN WEEKS NORMAL term
HOSPITAL COURSE ( include complications if any ) :
This 23 year old Gravida 2 Para 1001 was admitted to the Naliheall County Memorial Hospital Obstetrical service on 06/14/2001 at 01:29 pm for the indication ( s ) :
active labor .
She delivered a 3263 gram female infant at 06/14/2001 at 06:40 pm with apgar scores of 8 and 8 at one and five minutes respectively at 40.3 weeks gestation via vacuum extraction .
During her labor she encountered the following complication ( s ) :
fetal bradycardia .
During her delivery she encountered the following complication ( s ) :
nuchal cord , times two .
Postpartum she encountered the following complication ( s ) :
none .
She was discharged on 06/16/2001 at 12:00 pm in stable condition .
DISCHARGE ACTIVITY :
No Restrictions
DISCHARGE DIET :
No Restrictions
POSTPARTUM DISPOSITION :
Home With Self-Care ( Routine Discharge )
POSTPARTUM CARE SITE :
Burnrise Memorial Hospital
POSTPARTUM RETURN APPOINTMENT ( DAYS ) :
42
BREAST FEEDING AT DISCHARGE :
Yes
POSTPARTUM MEASLES / MUMPS/RUBELLA VACCINE :
Not Indicated
Electronically Signed :
American , 06/16/2001 5:14:05 PM