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Maternity Admission Note
HISTORY OF PRESENT ILLNESS: ***year old G*** P*** at ***weeks*** estimated gestational age by ***18-20 week ultrasound/early ultrasound/LMP*** presenting to Labor and Delivery for ***spontaneous onset of labor/spontaneous rupture of membranes/induction of labor/observation***. She reports continued fetal movement and no vaginal bleeding. Prenatal labs: ***blood type***, antibody screen ***negative/positive/unknown***, Syphilis ***IgG negative/RPR non-reactive/Syphilis IgG positive/Syphilis unknown***, Hepatitis B Virus Screening ***HBV S Ag Negative/HBV S Ag Positive/HBV S Ab Positive/HBV Unknown***, HIV ***Unknown/Negative/Positive***, Rubella ***Immune/Equivocal/Not Immune/Unknown***, GBS ***negative/positive/unknown***, Glucose tolerance testing: ***1 hr GTT, passed/1 hr GTT, failed/3 hr GTT, passed/3 hr GTT, failed***, ***Normal 18-20 week ultrasound/Abnormal ultrasound***. Pregnancy complications: ***Uncomplicated/GBS positive/GBS Unknown/Hepatitis B surface antigen positive/< 37 weeks gestation/PIH/Pre-eclampsia/Diabetes/Gestational diabetes/Multiple gestation/Breech presentation*** REVIEW OF SYSTEMS: All systems reviewed and negative except as noted per History of Present Illness
Exam: General: Well developed, well nourished gravid female in no acute distress. Vitals noted and stable. Lungs: Clear to auscultation bilaterally Cardiac: S1/S2, no S3/S4, no murmurs. Rhythm is regular Abdomen: Gravid, soft, nontender. FM palpable Extremities: Warm and well perfused. No clubbing, cyanosis or palpable cords Pelvic: Normal external female genitalia. Cervix is ***. EFW: *** Fetus is *** presentation by leopold's and bedside ultrasound
#1 ***Active Labor/Induction of Labor/Premature rupture of membranes*** -Admit to labor and delivery for management of labor -Begin augmentation with Pitocin -Begin cervical ripening with cytotec -Begin antibiotic prophylaxis for GBS positive status with Penicillin -Begin antibiotic prophylaxis for GBS positive status with Gentamycin
posted by: Mark Morgan, M.D.
post/review dates: April 1, 2010; September 4, 2015
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