Maternity hospital admission note


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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
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
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