Sex: F
Vaccine: UNK
Symptoms: Perineal injury, Pyrexia, SARS-CoV-2 test positive, Urinary tract infection
Clinical narrative: Date of Admission: 11/21/2023  3:10 AM Date of Discharge: 11/22/2023   Diagnoses:  Active Hospital Problems   Diagnosis    (Principal) SPONTANEOUS VAGINAL DELIVERY, UNCOMPLICATED         11/21 SVD at 370 after admit for labor. 1st degree. Was COVID + on delivery, mild symptoms IVF pregnancy   Estimated Date of Delivery: 12/11/23 Flu [ ]  Tdap [x ]  Covid [ ] Booster [ ]  ACES screening 16wk [ ]     PREDIABETES         12/11/2022   - Chart Update  Lab Results Component Value Date   Hgb A1c % 5.9 (H) 12/08/2022   New Weight loss, diet and exercise  Referred to health ed. Follow up in 1 year    CONTRACEPTIVE COUNSELING         11/22/2023 declines contraception on d/c     COVID-19 DISEASE IN PREGNANCY       Tested positive on labor admit 11/21/23 when reported URI s/s for approximately 1 week (fever, cough, nasal congestion)    BREASTFEEDING MOTHER    SINGLE UMBILICAL ARTERY       Referral to MFM placed    10/17/2023 - cephalic presentation, estimated fetal weight 1908g (39%)    PREDIABETES IN PREGNANCY       I reviewed the patient's chart and confirmed the following information with the patient regarding her medical history. Patient has PREDIABETES Onset of illness: 12/2022 Still being treated for this condition: no Current Medications: none Previous treatments including medications or surgery: advised to modify diet and exercise.  If she sees a clinician outside facility, name and location:none     Resolved Hospital Problems No resolved problems to display.      Male  Delivery Type: Vaginal, Spontaneous    Birth date/time: 11/xx/23  1:44 PM   Living status: Living Sex: Male  Apgar 1min: 8  Apgar 5min: 9    Weight: 2780 g    Delivering clinician:  (M.D.)    Labor and Delivery Complications  Labor Complications: None Shoulder Dystocia: No          Primary Procedures:  Male  Delivery Type: Vaginal, Spontaneous          Secondary Procedures:  Male  Placenta Removal: Spontaneous Anesthesia:                                 Episiotomy/Lacerations Episiotomy: None   Perineal lacerations: 1st Repaired: Yes Repaired with: 3-0 chromic                     Summary of Hospital Course: Patient was admitted for: Active Labor Her intrapartum course was: significant for COVID positive status with mild symptoms on admit. Her post delivery course was: unremarkable Complications: None   Subjective: No unusual complaints Pain: relieved with medications Bleeding: normal Voiding: normal Mobility: Walking without difficulty Breasts: no complaints   Physical Exam at discharge: BP 106/66  | Pulse 64  | Temp 98 °F (36.7 °C)  | Resp 16  | Ht 5' 1"  | Wt 68 kg (150 lb)  | LMP 03/05/2023  | SpO2 95%  | Breastfeeding Yes  | BMI 28.34 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:   Soft Abdomen:  soft, fundus well contracted and nontender Extremities:  no tenderness in the calves or thighs and no significant edema   Birth Control Plan: None-- she declined any at discharge    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 Contraceptive plan   MD        Note Details  Author (M.D.) File Time 11/22/2023 11:34 AM Author Type Physician Status Signed Last Editor (M.D.) Specialty Family Practice Hospital Acct  Admit Date 11/21/2023  Admission (Discharged) on 11/21/2023  Admission (Discharged) on 11/21/2023   Detailed Report  Note viewed by patient Additional Orders and Documentation   Results    Meds    Orders    Flowsheets   Encounter Info:  History, Allergies, Education, Care Plan, Detailed Report   Linked Episodes  Pregnancy Noted 4/20/2023  Hospital Problem List   SPONTANEOUS VAGINAL DELIVERY, UNCOMPLICATED  PREDIABETES IN PREGNANCY  SINGLE UMBILICAL ARTERY  COVID-19 DISEASE IN PREGNANCY  BREASTFEEDING MOTHER  CONTRACEPTIVE COUNSELING  PREDIABETES Care Timeline  11/21   Admitted 0406 11/22   Discharged 1640  Discharge   Home or Self Care.   Discharge Instructions (AVS) (Printed 11/22/2023) 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  ibuprofen 800 mg Oral EVERY 8 HOURS AS NEEDED, . Take with food  prenatal vit no.124/iron/folic,prenatal vit... Oral SHOWING PT IS NOT VACINNATED ON IMMUNIZATION RECORD