708739405 DH
0606127
65761
4209641
10/29/2003 12:00:00 AM
OB Discharge Summary
Signed
DIS
Report Status :
Signed OB EMR L and D
DISCHARGE SUMMARY
NAME :
SYSCO TAMARCE DOSE
UNIT NUMBER :
372-13-02
ADMISSION DATE :
20031029
DISCHARGE DATE :
20041101
PRINCIPAL DISCHARGE DIAGNOSIS :
Normal Vaginal Delivery
ASSOCIATED DIAGNOSES :
Current Smoker , history of ; Depression , history of ; Isoimmunization , Rh ; Undesired Fertility
PRINCIPAL PROCEDURE OR OPERATION :
Spontaneous Vertex Vaginal Delivery
ASSOCIATED PROCEDURES OR OPERATIONS :
POSTPARTUM DIAGNOSTIC PROCEDURES :
None
POSTPARTUM THERAPEUTIC PROCEDURES :
None
OTHER POSTPARTUM THERAPIES :
Pp Sterilization
HISTORY AND REASON FOR HOSPITALIZATION :
Early Labor / Rule Out Labor
PHYSICAL EXAMINATION :
HEIGHT HOSPITAL COURSE ( include complications if any ) :
This 22 year old Gravida 4 Para 2012 was admitted to the Naliheall County Memorial Hospital Obstetrical service on 10/29/2003 at 11:14 pm for the indication ( s ) : early labor / rule out labor .
She delivered a 3263 gram female infant on 10/30/2003 at 05:03 am with apgar scores of 8 and 9 at one and five minutes respectively at 40.1 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 ) :
nuchal cord , x 1- reduced prior to delivery .
Postpartum she encountered the following complication ( s ) :
none .
She was discharged on 11/01/2004 at 12:00 pm 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 :
Uval General Hospital
POSTPARTUM RETURN APPOINTMENT ( DAYS ) :
42
BREAST FEEDING AT DISCHARGE :
No
POSTPARTUM RH IMMUNE GLOBULIN :
Given
POSTPARTUM MEASLES / MUMPS/RUBELLA VACCINE :
Not Indicated
MEDICATION ( S ) ON DISCHARGE :
Multivitamins And Folate
Electronically Signed :
Ockgiernruss , Riret R 12/18/2003 7:53:30 PM