555509347 PUMC
7264645
16649
8815716
8/31/2004 12:00:00 AM
OB Discharge Summary
Signed
DIS
Report Status :
Signed OB EMR L and D
DISCHARGE SUMMARY NAME :
THON MERI CINKGUAY
UNIT NUMBER :
069-81-00
ADMISSION DATE :
20040831
DISCHARGE DATE :
20040903
PRINCIPAL DISCHARGE DIAGNOSIS :
Vaginal Delivery With Second Degree Laceration
ASSOCIATED DIAGNOSES :
Low Lying Placenta ; Past Medical History , history of ; Urinary Tract Infection , history of
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 :
Active Labor
PHYSICAL EXAMINATION :
HEIGHT 66 HEENT NORMAL NECK NORMAL BREASTS NORMAL NIPPLES NORMAL CHEST NORMAL COR NORMAL ABDOMEN NORMAL EXTREM NORMAL SKIN NORMAL NODES NORMAL VULVA NORMAL VAGINA NORMAL CERVIX NORMAL OS NORMAL ADNEXAE NORMAL UTERUS NORMAL UTERINE SIZE IN WEEKS NORMAL 12
HOSPITAL COURSE ( include complications if any ) :
This 34 year old Gravida 1 Para 0000 was admitted to the Bap Spald Hospital Obstetrical service on 08/31/2004 at 06:00 am for the indication ( s ) :
active labor .
She delivered a 3550 gram male infant on 08/31/2004 at 09:33 pm with apgar scores of 9 and 9 at one and five minutes respectively at 41.0 weeks gestation via spontaneous vertex vaginal delivery .
During her labor she encountered the following complication ( s ) :
chorioamnionitis .
During her delivery she encountered the following complication ( s ) :
nuchal cord .
Postpartum she encountered the following complication ( s ) :
none .
She was discharged on 09/03/2004 at 12:07 pm in good condition .
DISCHARGE ACTIVITY :
No Restrictions
DISCHARGE DIET :
No Restrictions
POSTPARTUM DISPOSITION :
Home With Self-Care ( Routine Discharge )
POSTPARTUM CARE SITE :
Cinpipecoursspi Hospital Health Center
POSTPARTUM RETURN APPOINTMENT ( DAYS ) :
42
BREAST FEEDING AT DISCHARGE :
Yes
POSTPARTUM MEASLES / MUMPS/RUBELLA VACCINE :
Not Indicated
MEDICATION ( S ) ON DISCHARGE :
Multivitamins And Folate ( Fam Pren Forte )
Electronically Signed :
Pada Post , MD
09/03/2004 9:51:35 PM