Age: 25.0
Sex: F
Vaccine: COVID19
Symptoms: Flatulence, Genital injury, Haemoglobin decreased, Haemorrhage, Maternal exposure before pregnancy
Clinical narrative: Date of Admission: 12/8/2023  3:26 AM Date of Discharge: 12/9/2023   Diagnoses:  Active Hospital Problems   Diagnosis   ? (Principal) SPONTANEOUS VAGINAL DELIVERY, UNCOMPLICATED        12/8/2023: 40w3d, Admitted in active labor, progressed unmedicated and delivered via SVD. QBL 100cc. R labial laceration repaired.    ? BREASTFEEDING MOTHER   ? COVID-19 DISEASE IN PREGNANCY       12/8/2023: COVID+ on admission in labor. Denies symptoms but occasional cough was noted.     Resolved Hospital Problems   Diagnosis Date Resolved ? SUPERVISION NORMAL PREGNANCY, LABOR CHECK 12/08/2023 ? ANEMIA IN PREGNANCY 12/09/2023       High risk for hemorrhage: No   PPH Risk Assessment on 9/7/2023 at 27w2d: High risk factors: None Medium risk factors: None  Overall she is at LOW risk for PPH (based on having No high risk factors and 0-1 medium risk factors)   Hgb:   Lab Results Component Value Date   Hgb 10.4 (L) 09/06/2023     Ferritin:   Lab Results Component Value Date   Ferritin 7 (L) 09/06/2023     9.7.23  Plan: currently 27w2d. Baseline ferritin updated. FeSO4 325mg q2d+c ordered on 9.7.23 -- > next labs due: 10.5.23   10.24.23   Lab Results Component Value Date   Hgb 10.4 (L) 10/20/2023    Lab Results Component Value Date   Ferritin 13 (L) 10/20/2023   Plan: currently 34w0d. FeSO4 325mg q2d+c ordered on 9.7.23 -- > hgb unchanged but ferritin up. Maximize po FeSO4 650mg q2d +c 500mg, adding iron rich diet ordered on 10.24.23 -- > next labs due: 11.7.23   11.7.23   Lab Results Component Value Date   Hgb 10.9 (L) 11/03/2023    Lab Results Component Value Date   Ferritin 12 (L) 11/03/2023   Plan: currently 36w0d.  FeSO4 650mg q2d +c 500mg ordered on 10.24.23 -- > hgb risen 10.9 with high dose po iron. Continue FeSO4 650mg q2d +c 500mg with iron rich diet -- > next labs due: n/a Hgb>10.5 DC pharmacy follow up          Female  Delivery Type: Vaginal, Spontaneous       Birth date/time: 8:16 AM      Living status: Living Sex: Female  Apgar 1min: 8  Apgar 5min: 8       Weight: 3490 g    Delivering clinician: (D.O.)       Labor and Delivery Complications  Labor Complications: None Shoulder Dystocia: No             Primary Procedures:  Female  Delivery Type: Vaginal, Spontaneous             Secondary Procedures:  Female  Placenta Removal: Spontaneous Anesthesia:  Method: Local Local Medication Used: Lidocaine 1%  Volume (mL): 10                                               Episiotomy/Lacerations Episiotomy: None      Perineal lacerations: None                 Other Lacerations: Labial     Labial laceration: right Repaired: Yes Repaired with: 3-0 Polysorb Labial Laceration Comment: R labial lac repaired w/ 2x figure of eight sutures             Summary of Hospital Course: Patient was admitted for: Active Labor Her intrapartum course was: unremarkable Her post delivery course was: unremarkable Complications: None   Subjective: No unusual complaints Pain: relieved with medications Bleeding: normal; denies excessive bleeding or clots Voiding: normal denies pain or difficulty with urination Diet and Bowel function: tolerating a regular diet and passing flatus Mobility: Walking without difficulty Breasts: Shares breastfeeding was going well, but that she is now having pain in her nipples (primarily her left nipple)   Patient plans to use condoms as birth control method   Physical Exam at discharge: BP 99/48  | Pulse 72  | Temp 97.6 °F (36.4 °C)  | Resp 18  | Ht 5' 2.01"  | Wt 90.1 kg (198 lb 9.6 oz)  | LMP 02/28/2023  | SpO2 99%  | Breastfeeding Yes  | BMI 36.32 kg/m²    General Appearance:  Alert, well appearing and in no distress Chest:  clear to auscultation, no wheezes, rales or rhonchi, symmetric air entry Heart:  regular rate and rhythm, no murmurs Breasts: intact; no bleeding or cracking noted on exam 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  Future Appointments       Appointment Date & Time Visit Type Provider Department/Facility   Dec 19, 2023 11:30 AM  Postpartum Phone Visit (N.P.)             MD          Cosigned by: (C.N.M.) at 12/9/2023  3:33 PM  Note Details  Author (M.D.) File Time 12/9/2023  3:33 PM Author Type PHYSICIAN, RESIDENT Status Addendum Last Editor  (C.N.M.) Specialty GENERAL, OTHER  Admit Date 12/8/2023  Admission (Discharged) on 12/8/2023  Admission (Discharged) on 12/8/2023   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 4/29/2023  Hospital Problem List   SPONTANEOUS VAGINAL DELIVERY, UNCOMPLICATED  ANEMIA IN PREGNANCY Resolved  SUPERVISION NORMAL PREGNANCY, LABOR CHECK Resolved  COVID-19 DISEASE IN PREGNANCY  BREASTFEEDING MOTHER  CONTRACEPTIVE METHOD SURVEILLANCE Care Timeline  12/08   Admitted 0403 12/09   Discharged 1337  Discharge   Home or Self Care.   Discharge Instructions (AVS) (Printed 12/9/2023) Medication List at Discharge   acetaminophen 500 mg Take 1 to 2 tablets by mouth every 6 hours as needed for pain. Do not exceed 6 tablets in 24 hours  ascorbic acid 500 mg Oral EVERY OTHER DAY, Take at the same time with iron  aspirin 81 mg Oral DAILY  cefadroxil 500 mg Oral 2 TIMES A DAY  ferrous sulfate 650 mg Oral EVERY OTHER DAY  ibuprofen 600 mg Oral EVERY 6 HOURS AS NEEDED, . Take with food  polyethylene glycol 3350 17 gram/dose Mix 17 Grams in 4 to 8 ounces of water or juice and drink by mouth daily for 6 weeks postpartum  prenatal vit/iron fum/folic ac 27 mg iron- 0.8 mg 1 tablet Oral DAILY  sennosides 8.6 mg Take 2 tablets by mouth at bedtime while taking opioid to prevent constipation. If not taking opioid, take 2 tablets daily as needed for constipation