OB-GYN Studies

DISCHARGE SUMMARY

ADMITTING DIAGNOSES

1. Intrauterine pregnancy at term.

2. Previous cesarean section.

FINAL DIAGNOSES

1. Intrauterine pregnancy, delivered.

2. Term birth living infant.

3. Vertex presentation.

4. Normal appendix.

COMPLICATIONS

None.

OPERATIONS

1. Repeat low transverse cervical cesarean section.

2. Incidental appendectomy.

3. Removal of mole from left mons.

CONDITION ON DISCHARGE

Improved.

HISTORY

This 20-year-old gravida 2, para 1, abortus 0, had an estimated date of confinement of April 10.  Patient was term by dates.  Ultrasounds x2 were consistent.  Patient was being admitted for a repeat low transverse cervical cesarean section and incidental appendectomy.

OPERATIONS

T&A at age 8.  Primary cesarean section secondary to a cord around the neck.

Physical exam was normal.  The cervix was thick and closed with a vertex presentation.  Estimated fetal size was 6 pounds
10 ounces.

HOSPITAL COURSE

On the day of admission, patient was taken to the operating room where she had a repeat low transverse cervical cesarean section, incidental appendectomy without incidents.  Postoperatively she began eating, ambulating, and voiding, was afebrile throughout her hospital course.  She received RhoGAM, for the infant was Rh positive and she was Rh negative, and she was discharged on her third postoperative day in good condition on Tylenol With Codeine 1/2 grain.

FOOTNOTE

Line 29 (Page 1).  The dictated ab was changed into abortus to maintain consistency.

Line 30 (Page 1).  The dictated 4/10 was changed to April 10.

Line 36 (Page 1).  The dictated numeral 2 was deleted because a vertical list format is not needed here.  The operations referred to here actually part of the past medical history.