tokens: 655358166 WGH 5367777 33714 8114836 10/12/2004 12:00:00 AM OB Discharge Summary Signed DIS Report Status : Signed OB EMR L and D DISCHARGE SUMMARY NAME : JUARISY DUHESMITRE UNIT NUMBER : 683-54-33 ADMISSION DATE : 20041012 DISCHARGE DATE : 20041015 PRINCIPAL DISCHARGE DIAGNOSIS : Vaginal Delivery With Second Degree Laceration ASSOCIATED DIAGNOSES : Abnormal Pap Test , history of ; Bacterial Vaginitis ; Contraception Management ; Hiv Counseled PRINCIPAL PROCEDURE OR OPERATION : Spontaneous Vertex Vaginal Delivery ASSOCIATED PROCEDURES OR OPERATIONS : POSTPARTUM DIAGNOSTIC PROCEDURES : None OTHER POSTPARTUM THERAPIES : Antimicrobial Therapy HISTORY AND REASON FOR HOSPITALIZATION : Srom In Labor PHYSICAL EXAMINATION : MOUTH NORMAL NECK NORMAL thyroid wnl BREASTS NORMAL no distinct masses NIPPLES NORMAL inverted [ b ] , evert w / stimulation CHEST NORMAL LCTA COR NORMAL RRR ABDOMEN NORMAL gravid EXTREM NORMAL SKIN NORMAL NODES NORMAL VULVA NORMAL no lesions , white d / c at introitus VAGINA NORMAL sml amt thin white d / c ph 4.5 , koh +amine , NS +clue , neg trich CERVIX NORMAL 1/100/0 srom clear OS NORMAL closed ADNEXAE NORMAL no palp masses , NT UTERUS NORMAL gravid UTERINE SIZE IN WEEKS NORMAL term RECTUM NORMAL no ext lesions HOSPITAL COURSE ( include complications if any ) : This 21 year old Gravida 2 Para 0010 was admitted to the Life Valley Medical Center Obstetrical service on 10/12/2004 at 08:41 am for the indication ( s ) : srom in labor . She delivered a 3680 gram male infant on 10/12/2004 at 10:17 pm with apgar scores of 9 and 9 at one and five minutes respectively at 40.0 weeks gestation via spontaneous vertex vaginal delivery . During her labor she encountered the following complication ( s ) : srom . During her delivery she encountered the following complication ( s ) : none . Postpartum she encountered the following complication ( s ) : none . She was discharged on 10/15/2004 at 01:52 pm in good condition . DISCHARGE ACTIVITY : No Restrictions DISCHARGE DIET : No Restrictions POSTPARTUM DISPOSITION : Home Under Care Of Home Health Agency POSTPARTUM CARE SITE : Alle Rehabilitation Hospital POSTPARTUM RETURN APPOINTMENT ( DAYS ) : 42 BREAST FEEDING AT DISCHARGE : Yes MEDICATION ( S ) ON DISCHARGE : Metronidazole Tablets ( Flagyl ) ; Multivitamins And Folate Capsules ( Stuart Prenatal With Folate ) Electronically Signed : Thorerogodlethrelf , Cisperna M 10/17/2004 6:01:02 PM