OB-GYN Case Study

DISCHARGE SUMMARY

PROVISIONAL DIAGNOSIS

Intrauterine pregnancy.

FINAL DIAGNOSES

1. Intrauterine pregnancy, delivered.

2. Periurethral tear.

OPERATIONS

None.

HISTORY AND ESSENTIAL PHYSICAL

This is a 27-year-old secundigravida at term, with blood type A positive, who had a pregnancy uncomplicated except for some first-trimester bleeding.  She was admitted after 5 hours of good labor and was brought to the delivery room, complete and pushing, with membranes still intact.  Spontaneous rupture of membranes occurred only 1 minute prior to delivery and revealed light meconium staining.  The delivery was very rapid, though well controlled, and resulted in a superficial periurethral and labial tear which did not require suturing.  No episiotomy required.  The infant was suctioned well on the perineum.  Blood loss was minimal, and both mother and infant were stable following delivery.

HOSPITAL COURSE

Large uterine clots were expressed the first postpartum day, and the initial postpartum CBC revealed a white count of 18.5 with
55 segs, 17 bands, and 23 lymphs.  This was repeated on the second postpartum day and showed white count 16,000 with 69 segs, 7 bands, 19 lymphs, hemoglobin 11.8, hematocrit 35.2.

The patient remained afebrile but had minimal uterine tenderness, and in light of the elevated white count, she was begun on ampicillin 500 mg q.i.d. for a 10-day course.  She was discharged in stable condition.  Activity and diet as tolerated.  To continue Parlodel, ampicillin, prenatal vitamins, and ferrous sulfate as directed, also Colace 100 mg q.h.s. p.r.n. constipation.  Appointment for 6-week postpartum check, but should call sooner if high fever or excessive uterine cramps persist.