655358166 WGH
5367777
33714
8114836
10/12/2004 12:00:00 AM
OB Discharge Summary
Signed
DIS
Report Status :
Signed OB EMR L and D
DISCHARGE SUMMARY
NAME :
JUARISY DUHESMITRE
UNIT NUMBER :
683-54-33
ADMISSION DATE :
20041012
DISCHARGE DATE :
20041015
PRINCIPAL DISCHARGE DIAGNOSIS :
Vaginal Delivery With Second Degree Laceration
ASSOCIATED DIAGNOSES :
Abnormal Pap Test , history of ; Bacterial Vaginitis ; Contraception Management ; Hiv Counseled
PRINCIPAL PROCEDURE OR OPERATION :
Spontaneous Vertex Vaginal Delivery
ASSOCIATED PROCEDURES OR OPERATIONS :
POSTPARTUM DIAGNOSTIC PROCEDURES :
None
OTHER POSTPARTUM THERAPIES :
Antimicrobial Therapy
HISTORY AND REASON FOR HOSPITALIZATION :
Srom In Labor
PHYSICAL EXAMINATION :
MOUTH NORMAL NECK NORMAL thyroid wnl BREASTS NORMAL no distinct masses NIPPLES NORMAL inverted [ b ] , evert w / stimulation CHEST NORMAL LCTA COR NORMAL RRR ABDOMEN NORMAL gravid EXTREM NORMAL SKIN NORMAL NODES NORMAL VULVA NORMAL no lesions , white d / c at introitus VAGINA NORMAL sml amt thin white d / c ph 4.5 , koh +amine , NS +clue , neg trich CERVIX NORMAL 1/100/0 srom clear OS NORMAL closed ADNEXAE NORMAL no palp masses , NT UTERUS NORMAL gravid UTERINE SIZE IN WEEKS NORMAL term RECTUM NORMAL no ext lesions
HOSPITAL COURSE ( include complications if any ) :
This 21 year old Gravida 2 Para 0010 was admitted to the Life Valley Medical Center Obstetrical service on 10/12/2004 at 08:41 am for the indication ( s ) :
srom in labor .
She delivered a 3680 gram male infant on 10/12/2004 at 10:17 pm with apgar scores of 9 and 9 at one and five minutes respectively at 40.0 weeks gestation via spontaneous vertex vaginal delivery .
During her labor she encountered the following complication ( s ) :
srom .
During her delivery she encountered the following complication ( s ) :
none .
Postpartum she encountered the following complication ( s ) :
none .
She was discharged on 10/15/2004 at 01:52 pm in good condition .
DISCHARGE ACTIVITY :
No Restrictions
DISCHARGE DIET :
No Restrictions
POSTPARTUM DISPOSITION :
Home Under Care Of Home Health Agency
POSTPARTUM CARE SITE :
Alle Rehabilitation Hospital
POSTPARTUM RETURN APPOINTMENT ( DAYS ) :
42
BREAST FEEDING AT DISCHARGE :
Yes
MEDICATION ( S ) ON DISCHARGE :
Metronidazole Tablets ( Flagyl ) ; Multivitamins And Folate Capsules ( Stuart Prenatal With Folate )
Electronically Signed :
Thorerogodlethrelf , Cisperna M 10/17/2004 6:01:02 PM