Spontaneous abortion without mention of complication incomplete
 
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:
preterm premature rupture of membranes
 
Major Surgical or Invasive Procedure:
Dilation and Evacuation

 
History of Present Illness:
___ G1P0 @ 18w6d by LMP presenting after she felt a gush of
clear fluid yesterday that has continued intermittenly and
required her to wear a pad since. She denies VB and ctx. She has
not felt sick: no fevers/chills, no urinary or vaginal symptoms,
regular bowel movements, no rashes, no N/V. Reports mild
abdominal discomfort in LLQ that feels like "a muscle pull" that
started 2 days ago. Feels the discomfort w/ movement and
palpation. Has been feeling stressed and tired secondary to a
recent move. 
Pregnancy uncomplicated other than bleeding from a cervical 
polyp
earlier in the pregnancy. The patient is s/p coloscopy ___ which
was technically unsatisfactory, no features of premalignant dz -
recommendation for f/u in 2 months.

 
Past Medical History:
POBHx:
-G1

PGynHx: 
-Denies STDs (husband w/ hx of chlamydia) 
-pap ___ ASC-US, negative HPV 
-Colpo ___: technically unsatisfactory, large
vascular endocervical polyp without features of premalignant
disease. Rec: f/u for repeat evaluation of polyp in 2
months

PMH:
-ulcerative colitis dx ___ ago, currently in remission, no 
sxs,
no meds, last hospitalized for flare ___

PSH:
-none

 
Social History:
___
Family History:
Non-contributory
 
Physical Exam:
PE: T 98.4 HR 89 BP 108/69 O2 100% RA
NAD
CTA bilaterally
RRR
Abd soft, gravid, mildly tender to deep palpation in the left
lower quadrant.
SVE: cervix closed
SSE: approx. 1cm friable appearing endocervical polyp, os 
appears
closed, gush of fluid visible from cervix, +pooling, +nitrazine,
+ferning

 
Pertinent Results:
___ 05:40PM   ___ PTT-23.5 ___
___ 11:25AM URINE  COLOR-Straw APPEAR-Clear SP ___
___ 11:25AM URINE  BLOOD-NEG NITRITE-NEG PROTEIN-NEG 
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 
LEUK-MOD
___ 11:25AM URINE  RBC-0 WBC-1 BACTERIA-FEW YEAST-NONE 
EPI-<1
___ 10:55AM   WBC-11.0 RBC-3.68* HGB-12.0 HCT-32.6* MCV-89 
MCH-32.5*# MCHC-36.7*# RDW-13.4
___ 10:55AM   NEUTS-85.0* LYMPHS-9.6* MONOS-4.6 EOS-0.5 
BASOS-0.3
___ 10:55AM   PLT COUNT-282
 
Brief Hospital Course:
Ms. ___ was admitted to the gynecology service after being 
found to have preterm premature rupture of membranes at 
approximately 19 weeks gestational age. There was nothing in the 
patient's history or evaluation to suggest an etiology for 
PPROM. Options for management were discussed with the patient 
and her husband and they elected for a dilation and evacuation 
procedure. Laminaria were placed for cervical dilation. She was 
admitted overnight for pain control as well as intravenous 
antibiotics for prevention/treatment of chorioamnionitis. On 
HD#2 the patient underwent an uncomplicated D&E. For full 
details of the procedure please see Dr. ___ report. 
The patient recovered well from the procedure and was discharged 
home on POD#0/HD#2, ambulating, eating a regular diet, voiding, 
with pain controlled on oral medication with instructions to 
follow up with her primary Ob/Gyn. She was given a prescription 
for a course of Doxycycline to finish a total of 7 days of 
antibiotic treatment.  
 
Medications on Admission:
prenatal vitamin
 
Discharge Medications:
1. oxycodone-acetaminophen ___ mg Tablet Sig: ___ Tablets PO 
Q4H (every 4 hours) as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
2. doxycycline hyclate 100 mg Capsule Sig: One (1) Capsule PO 
twice a day for 6 days.
Disp:*12 Capsule(s)* Refills:*0*

 
Discharge Disposition:
Home
 
Discharge Diagnosis:
preterm premature rupture of membranes

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

 
Discharge Instructions:
Please take your medications as prescribed. Do not drink alcohol 
or operate machinery while taking percocet.
Do not take a shower for 24hrs.
Do not take a tub bath or swim for 1 week.
Nothing in the vagina (no tampons/intercourse) for 2 weeks.

 
Followup Instructions:
___

{'abdominal discomfort': ['Spontaneous abortion', 'without mention of complication', 'incomplete'], 'clear fluid': ['Spontaneous abortion', 'without mention of complication', 'incomplete'], 'feeling stressed': ['Spontaneous abortion', 'without mention of complication', 'incomplete'], 'tired': ['Spontaneous abortion', 'without mention of complication', 'incomplete'], 'mild abdominal discomfort': ['Spontaneous abortion', 'without mention of complication', 'incomplete'], 'muscle pull': ['Spontaneous abortion', 'without mention of complication', 'incomplete']}