Age: 32.0
Sex: F
Vaccine: COVID19
Symptoms: Genital injury, Laboratory test normal, Meconium in amniotic fluid, Oropharyngeal pain, Pathology test
Clinical narrative: Date of Admission: 10/22/2023  4:40 AM Date of Discharge: 10/24/2023   Diagnoses:  Active Hospital Problems   Diagnosis   ? (Principal) SPONTANEOUS VAGINAL DELIVERY, UNCOMPLICATED       SVD, epidural, manual removal of placenta (2g Ancef), QBL 881, 2nd degree lac repaired.  + Meconium.  Admit for Preterm PROM followed by spontaneous labor. Suspect chronic abruption based on port-wine stained fluid noted at delivery.    BMTZ x 1   EDD 11/14/2023 Expecting a girl, plans to breastfeed FOB:  BF: yes Blood Products: yes HSV: yes Covid Vaccine: yes   ? BREASTFEEDING MOTHER   ? COVID-19 DISEASE IN PREGNANCY       tested positive for COVID 19 on Labor and Delivery Sore throat since 10/21/2023 Husband has covid, symptomatic since 10/19/2023   ? PREECLAMPSIA WO SEVERE FEATURES       Mild range BPs, UPC 1.27, asymptomatic Serum labs normal     ? PRURITIC URTICARIAL PAPULES AND PLAQUES OF PREGNANCY        10/18/2023 (OB/GYN) - DOV  Using atarax TID, but still waking up 2AM with severe itching. Acetaminophen helps, aloe and calamine lotion.      ? CONTRACEPTIVE COUNSELING       Wants condoms after delivery   ? RETAINED PLACENTA WO HEMORRHAGE       Retained placenta with manual removal (Ancef 2-gm). Marginal cord insertion. Suspect chronic abruption based on port-wine staining of fluid noted at delivery and umbilical cord with port-wine staining. Calcifications noted. Placenta sent to pathology.  Velamentous insertion noted by U/S in pregnancy.    ? HX OF DEPRESSION   ? HX OF URETERAL REIMPLANTATION       Patient unable to get medical records- unsure how they were reimplanted but thinks they were on the "top" of the bladder   ? HX OF PARTIAL NEPHRECTOMY       In pregnancy MFM Recs: Level 2 US, urine culture q trimester for r/o asx bacteriuria- low threshold for macrobid ppx  Close attention to atypical ureteral location if needing cesarean section   At 3yo; h/o bilateral ureteral reimplant; right upper pole nephrectomy Seen by urology: 2011 Work-up: renal sono showing atrophic right kidney w/ 26 % fxn  VCUG showing no reflux and normal cystoscopy   Discussed with Urology, no further imaging recommended this pregnancy     ? GENITAL HERPES SIMPLEX       Not confidential from partner [X] 36wk ppx      Resolved Hospital Problems   Diagnosis Date Resolved ? PRETERM PROM, ONSET OF LABOR UNKNOWN       @36w5d     ? EXCESSIVE WEIGHT GAIN IN PREGNANCY       29.5 kg (65 lb)          Female  Delivery Type: Vaginal, Spontaneous    Birth date/time:  4:39 PM   Living status: Living Sex: Female  Apgar 1min: 8  Apgar 5min: 9    Weight: 3780 g Observed anomalies, comments: None noted at this time    Delivering clinician: (C.N.M.)    Labor and Delivery Complications  Labor Complications: Abruptio Placenta, Meconium staining, Premature rupture of membranes, Retained Placenta Shoulder Dystocia: No          Primary Procedures:  Female  Delivery Type: Vaginal, Spontaneous          Secondary Procedures:  Female  Placenta Removal: Manual Removal Anesthesia:  Method: Epidural, Local Local Medication Used: Lidocaine 1%  Volume (mL): 8                             Episiotomy/Lacerations Episiotomy: None   Perineal lacerations: 2nd Repaired: Yes Repaired with: 3-0 Polysorb Perineal Laceration Comment: Repaired in the usual fashion     Other Lacerations: Labial     Labial laceration: right Repaired: No   Labial Laceration Comment: Hemostatic, well-approximated, no repair indicated          Summary of Hospital Course: Patient was admitted for: PPROM, Not in Labor Her intrapartum course was: significant for preeclampsia without severe features, and COVID positive. Likely placental abruption diagnosed at delivery, followed by retained placenta requiring manual extraction Her post delivery course was: unremarkable Complications: retained placenta   Subjective: No unusual complaints Pain: relieved with medications Bleeding: normal Voiding: normal Diet and Bowel function: tolerating a regular diet Mobility: Walking without difficulty Breasts: no complaints   Physical Exam at discharge: BP 136/91  | Pulse 98  | Temp 97.6 °F (36.4 °C)  | Resp 18  | Ht 5' 7"  | Wt 114.3 kg (252 lb)  | LMP 02/07/2023 (Exact Date)  | SpO2 98%  | Breastfeeding Yes  | BMI 39.47 kg/m²    General Appearance:  Alert, well appearing and in no distress Chest:  Normal respirations   Abdomen:  soft, fundus well contracted and nontender   Extremities:  no tenderness in the calves or thighs and no significant edema   Birth Control Plan: condoms    Condition on discharge:  Patient is medically stable for discharge and agrees with the plan of care.  If the patient?s condition changes prior to discharge, this Discharge Summary will be updated.   Discharge Disposition: Discharged home   Medications/Activity/Follow-up/Patient Instructions: See patient discharge instructions.   Pending Study Results at Discharge: None   Issues to be Addressed in Follow-up: Routine postpartum care Contraception Blood pressure monitoring       Note Details  Author (M.D.) File Time 10/24/2023  9:46 AM Author Type Physician Status Signed Last Editor  (M.D.) Specialty Obstetrics & Gynecology Hospital Acct #  Admit Date 10/22/2023  Admission (Discharged) on 10/22/2023  Admission (Discharged) on 10/22/2023   Detailed Report  Note shared with patient Additional Orders and Documentation   Results    Meds    Orders    Flowsheets   Encounter Info:  History, Allergies, Education, Care Plan, Detailed Report   Linked Episodes  Pregnancy Noted 3/23/2023 CESAREAN SECTION From   Hospital Problem List   HX OF PARTIAL NEPHRECTOMY  HX OF URETERAL REIMPLANTATION  HX OF DEPRESSION  GENITAL HERPES SIMPLEX  EXCESSIVE WEIGHT GAIN IN PREGNANCY Resolved  RETAINED PLACENTA WO HEMORRHAGE  CONTRACEPTIVE COUNSELING  PRURITIC URTICARIAL PAPULES AND PLAQUES OF PREGNANCY  PREECLAMPSIA WO SEVERE FEATURES  PRETERM PROM, ONSET OF LABOR UNKNOWN Resolved  COVID-19 DISEASE IN PREGNANCY  SPONTANEOUS VAGINAL DELIVERY, UNCOMPLICATED  BREASTFEEDING MOTHER Care Timeline  10/22   Admitted 0501 10/24   Discharged 1630  Discharge   Home or Self Care.   Discharge Instructions (AVS) (Printed 10/24/2023) Medication List at Discharge   acetaminophen 1,000 mg Oral EVERY 6 HOURS AS NEEDED  acyclovir 400 mg Oral 3 TIMES A DAY, until delivery for suppression  albuterol sulfate 90 mcg/actuation 2 Puffs Inhalation EVERY 6 HOURS AS NEEDED  guaifenesin 50 mg Oral EVERY 6 HOURS AS NEEDED  hydroxyzine HCl 25 mg Oral 3 TIMES A DAY AS NEEDED  prenatal vit no.124/iron/folic,prenatal vit... Oral  triamcinolone acetonide 0.1 % Topical 3 TIMES A DAY Pt in house Bed