Sex: F
Vaccine: UNK
Symptoms: Breast feeding, COVID-19, Cervical dilatation, Cough, Discomfort
Clinical narrative: Antepartum Discharge Summary   Date of Admission: 12/5/2023 10:17 AM   Date of Discharge: 12/6/2023   Diagnoses:  Active Hospital Problems   Diagnosis   ? (Principal) PRETERM UTERINE CONTRACTIONS       12/6/2023:3/60/-2/mid/soft, BOW intact, cephalic, 2nd dose of betamethasone given. D/C home not in labor.  12/5/23: preterm contractions, 2cm->3.5cm, admit for preterm labor, start betamethasone   10/23/2023 (OB/Gyn) - Hospital  Patient seen in triage at 29w1d with discomfort x2 hours. Has been having pelvic pressure lately as well. Reports first pregnancy she had preterm contractions and was found to be 9 cm at 35 weeks with no painful contractions. Delivered soon after AROM. Very nervous. Had serial cervical lengths from 16-23 weeks gestation.   CL 2.63 - 2.92 cm with no dynamic changes during a contractions   Discharged home with preterm labor precautions.   ? COVID-19 DISEASE IN PREGNANCY       Tested positive on 11/28/23   ? HX OF PRETERM DELIVERY       - delivered at 35 weeks, does not qualify for RPSC [x] transvaginal ultrasound for cervical lengths every 1-4 weeks from 16 w to 23w6d per regional guidelines - 16w: shortest length 2.87 (average >3.0cm) - 18wks: shortest 2.59 (average 3.21), no dynamic changes - 20wks: (formal US in Radiology), CL 4.0cm - 22w5d: CL 3.1 - 3.4cm, no funneling   ? SUPERVISION HIGH RISK PREGNANCY, HX PRETERM LABOR IN PRIOR PREGNANCY       Estimated Date of Delivery: 1/7/24 Flu [ ] - declined 10/11/23 Tdap [x]  Covid [ ] Booster [ ]  ACES screening 16wk [x]    History PTD/PTL at 35 weeks     Resolved Hospital Problems No resolved problems to display.     Procedures: Ultrasound or Procedures   Complications: none   Summary of Hospital Course/Significant Findings: See Diagnoses above Gestational age at discharge: 35w3d Admitted on 12/5/2023 for preterm contractions causing cervical change from 2 to 3.5cm. Received betamethasone IM. Contractions slowed overnight, now irregular. Received 2nd dose of betamethasone IM. Cervix unchanged over ~ 24 hours.  Tested positive for COVID 11/28/23, continues to have congestion and occasional coughing but no other complaints related to this illness. Will be out of isolation    Subjective:  Patient no new complaints and contractions less painful and frequent   Objective: BP 120/79  | Pulse 97  | Temp 97.9 °F (36.6 °C)  | Resp 18  | LMP 04/02/2023  | SpO2 96%  | Breastfeeding Yes  Patient Vitals for the past 24 hrs:    BP Temp Pulse Resp SpO2 12/06/23 1629 111/68 98.2 °F (36.8 °C) 90 14 98 % 12/06/23 1100 120/79 97.9 °F (36.6 °C) 97 18 96 % 12/06/23 0752 ? ? ? ? 97 % 12/06/23 0745 127/74 98.1 °F (36.7 °C) 95 16 ? 12/05/23 2347 113/63 96.6 °F (35.9 °C) 83 14 ? 12/05/23 2015 130/83 98 °F (36.7 °C) 92 16 ?   Physical Exam: General: alert, well appearing, in no apparent distress Skin:  normal coloration and turgor, no rashes HEENT:  normocephalic, atraumatic Abdomen: soft, nontender, nondistended, no abnormal masses, no epigastric pain and FHT present, Reactive NST Extremities: no redness or tenderness in the calves or thighs, no edema   Last Cervical Exam: Vaginal Exam: COMPLETED (12/05/23 1113) Dilation (cm): 3 CM (12/06/23 1600) Effacement (%): 60 % (12/06/23 1600) Station: -2 (12/06/23 1600) Cervical Characteristics: MID POSITION (12/05/23 1340) Presentation: VERTEX (12/05/23 1340)   Fetal Monitoring: BABY A Fetal Assessment - If Maternal HR above 105 or within 10 beats of baseline FHR place pulse oximeter or FSE to distinguish Maternal HR from FHR.  Notify Provider for MHR above 120.   Assessment Mode: External (Ultrasound);Removed (12/06/23 1553) Variability: MODERATE (12/06/23 1553) Baseline Fetal Heart Rate (Baby A): 135 (12/06/23 1553) Baseline Changes: No Baseline Change (12/06/23 1030) Accelerations: 15X15 (12/06/23 1553) Decelerations: None (12/06/23 1553) Recurrent Periodic Changes: YES (12/06/23 1553) Interpretation: Category I (12/06/23 1330) Intervention: Ultrasound Monitor Adjusted (12/06/23 1448) Alarms: PARAMETERS VERIFIED;ALL ALARM(S) ON (12/06/23 1553) Presentation on last ultrasound: Vertex Selected Results: Last Gr B Strep result in 7 weeks (if any)  Recent Results (from the past 1176 hour(s)) GROUP B STREPTOCOCCUS PRENATAL SCREENING CULTURE     Status: None   Collection Time: 11/14/23 12:00 PM   Specimen: VAGINAL/RECTAL SWAB Result Value   Strep B culture result       Final Report Negative For Group B Streptococcus.      Recent Labs   12/05/23 1420 HCT 38.3 PLT 200     Condition on discharge:  Stable, not in labor.   Discharge Disposition:  Patient is 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: Office visit next week Consider RSV vaccine if recovered from COVID by 36w6d Encouraged pelvic rest, light activity and increase to tolerance over the next week. Reviewed PTL signs   Future Appointments    Appointment Date & Time Visit Type Provider Department/Facility   Dec 13, 2023  3:15 PM Prenatal Office Visit  (M.D.) WOMEN'S HEALTH     CNM               Cosigned by: (M.D.) at 12/6/2023  4:57 PM  Note Details  Author (C.N.M.) File Time 12/6/2023  4:50 PM Author Type CERTIFIED NURSE MIDWIFE Status Signed Last Editor (C.N.M.) Specialty GENERAL, OTHER  Admit Date 12/5/2023  Admission (Discharged) on 12/5/2023  Admission (Discharged) on 12/5/2023   Revision History   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 5/16/2023  Hospital Problem List   HX OF PRETERM DELIVERY  SUPERVISION HIGH RISK PREGNANCY, HX PRETERM LABOR IN PRIOR PREGNANCY  COVID-19 DISEASE IN PREGNANCY  PRETERM UTERINE CONTRACTIONS Care Timeline  12/05   Admitted 1404 12/06   Discharged 1640  Discharge   Home or Self Care.   Discharge Instructions (AVS) (Printed 12/6/2023) Medication List at Discharge   prenatal vit calc,iron,folic 1 tablet Oral DAILY  sertraline HCl 50 mg DAILY In HC pt showing NOT Vaccinated