tokens: 212512774 WGH 6218589 29021 9923207 10/31/2004 12:00:00 AM OB Discharge Summary Signed DIS Report Status : Signed OB EMR L and D DISCHARGE SUMMARY NAME : RIASHWAN BERLNI VALLEY UNIT NUMBER : 130-93-91 ADMISSION DATE : 20041031 DISCHARGE DATE : 20041103 PRINCIPAL DISCHARGE DIAGNOSIS : Vaginal Delivery With Second Degree Laceration ASSOCIATED DIAGNOSES : Abnormal Laboratory Result ; Abnormal Pap Test ; Monilial Vaginitis PRINCIPAL PROCEDURE OR OPERATION : Spontaneous Vertex Vaginal Delivery ASSOCIATED PROCEDURES OR OPERATIONS : POSTPARTUM DIAGNOSTIC PROCEDURES : None POSTPARTUM THERAPEUTIC PROCEDURES : None OTHER POSTPARTUM THERAPIES : Routine Post Partum Care HISTORY AND REASON FOR HOSPITALIZATION : Premature Rupture Of Membranes PHYSICAL EXAMINATION : HEIGHT 63 HEENT NORMAL MOUTH NORMAL NECK NORMAL BREASTS NORMAL No masses NIPPLES NORMAL CHEST NORMAL CTA bilat , neg wheezing COR NORMAL NSR , no murmur ABDOMEN Gravid , vtx . EFW = 7# . FHTs 140s w/ reactivity . Mild irreg. ctx . EXTREM NORMAL SKIN NORMAL NODES NORMAL VULVA NORMAL VAGINA Leaking copious amounts clear fluid . Fluid amnioswab and fern positive . SSE and digital exam deferred CERVIX digital exam deferred at time of admission OS NORMAL see above ADNEXAE NORMAL non-palp d / t advanced gest UTERUS Gravid , vtx . EFW = 7# . FHTs 140s w/ reactivity . Ctx q 6 &apos; . UTERINE SIZE IN WEEKS 38 HOSPITAL COURSE ( include complications if any ) : This 27 year old Gravida 1 Para 0000 was admitted to the Life Valley Medical Center Obstetrical service on 10/31/2004 at 08:45 pm for the indication ( s ) : premature rupture of membranes . She delivered a 3235 gram male infant on 11/01/2004 at 09:31 am with apgar scores of 9 and 9 at one and five minutes respectively at 39.0 weeks gestation via spontaneous vertex vaginal delivery . During her labor she encountered the following complication ( s ) : none . During her delivery she encountered the following complication ( s ) : none . Postpartum she encountered the following complication ( s ) : none . She was discharged on 11/03/2004 at 11:18 am in good condition . DISCHARGE ORDERS ( medications instructions to patient , follow-up care ) : DISCHARGE ACTIVITY : No Restrictions DISCHARGE DIET : No Restrictions POSTPARTUM DISPOSITION : Home With Self-Care ( Routine Discharge ) POSTPARTUM CARE SITE : La Community Hospital POSTPARTUM RETURN APPOINTMENT ( DAYS ) : 42 BREAST FEEDING AT DISCHARGE : Yes POSTPARTUM RH IMMUNE GLOBULIN : Not Indicated POSTPARTUM MEASLES / MUMPS / RUBELLA VACCINE : Not Indicated MEDICATION ( S ) ON DISCHARGE : Multivitamins And Folate Electronically Signed : Fyfe , Lan S 11/03/2004 11:19:27 AM