Early onset of delivery delivered with or without mention of antepartum condition Cervical shortening delivered with or without mention of antepartum condition Outcome of delivery single liveborn Abnormal glucose tolerance of mother delivered with or without mention of antepartum condition First-degree perineal laceration delivered with or without mention of antepartum condition Elderly multigravida delivered with or without mention of antepartum condition
 
Name:  ___         Unit No:   ___
 
Admission Date:  ___              Discharge Date:   ___
 
Date of Birth:  ___             Sex:   F
 
Service: OBSTETRICS/GYNECOLOGY
 
Allergies: 
No Known Allergies / Adverse Drug Reactions
 
Attending: ___.
 
Chief Complaint:
cramping
 
Major Surgical or Invasive Procedure:
vaginal delivery
 
History of Present Illness:
___ y/o G5P0040 GDMA, ___ ___ presents to triage with the
complaint of cramping and lower back pain. she states the
cramping began yesterday and decided that if still cramping 
would
call in the morning. she denies vaginal spotting or leaking.
Active fetal movements.
 
Past Medical History:
PNC
*) Dating ___ ___ by LMP consistant w/7+4 wk u/s
*) Labs: AB pos/Ab neg/R-I/RPR-NR/HBsAg neg/HIV negHCV neg
*) FFS unremarkable, placenta anterior no previa, cl 44mm
*) glucola: ___ ___ ___
issues
short CL,on vaginal progesterone, received BMZ and complete on
___.
GDMA1

OBHx TAB x 2
     SAB x 2
GYNHx LMP ___ 
      LEEP
      denies STI's
PMH benign
 
Social History:
___
Family History:
noncontributory
 
Physical Exam:
O:
BP 126/73  HR 92  RR 14  temp 98
RRR
CTA B
ABD gravid, soft, NT

FHT 145 ___, AGA
Toco ctx q ___  mins

fFN obtain but not sent given a change in cx
SVE 1.5cm/100/BBOW
cephalic by U/S
 
Brief Hospital Course:
Pt was initially found to be 1.5cm dilated. She was observed on 
the antepartum service and kept on bedrest. On the morning of 
___, her cramping increased and became painful, she was 
found the be 7cm dilated and in active labor.  She was 
transferred to L&D and had an uncomplicated vaginal delivery of 
a liveborn male, who was brought to NICU. 

She did well postpartum and was discharged home on PPD#2.
 
Medications on Admission:
prenatal vitamins
insulin
 
Discharge Medications:
1. Ibuprofen 600 mg PO Q6H:PRN Pain 
RX *ibuprofen 600 mg 1 tablet(s) by mouth every six (6) hours 
Disp #*60 Tablet Refills:*0

 
Discharge Disposition:
Home
 
Discharge Diagnosis:
preterm labor, insulin requiring gestational diabetes

 
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.

 
Discharge Instructions:
pelvic rest
 
Followup Instructions:
___

{'cramping': ['Early onset of delivery', 'Abnormal glucose tolerance of mother'], 'lower back pain': ['Early onset of delivery', 'Abnormal glucose tolerance of mother'], 'vaginal spotting': [], 'leaking': [], 'Active fetal movements': []}