DATE OF ADMISSION: MM/DD/YYYY
DATE OF DISCHARGE: MM/DD/YYYY
DISCHARGE DIAGNOSES: Intrauterine gestation at term, in labor, previous cesarean section, multiparity, fertility, desired sterilization, delivery of viable female infant.
PROCEDURES: Repeat low transverse cesarean section, bilateral tubal ligation, and lysis of adhesions.
COMPLICATIONS: None. Level of pain at discharge, mild, 3/10.
PERTINENT FINDINGS AND HISTORY: Please refer to the detailed admission dictation as well as the written history and physical. The patient is a (XX)-year-old gravida 2, para 1 female with an EDC of MM/DD/YYYY, who presented at 38.6 weeks gestation in labor with contractions recurring every 1-1/2 to 2 minutes of moderate intensity. The patient had history of having undergone a primary cesarean section with her first pregnancy in YYYY for failure to descend. Our plan with this pregnancy was to proceed with a repeat cesarean section. The patient also strongly desired sterilization at the time of this delivery. She had been counseled regarding the permanency, failure rates, risks, and options. Her antenatal course had been benign. She did have a history of asthma and was using Advair twice daily along with Zyprexa and albuterol nebulizers as needed. The patient has not had any recent problems with her asthma. On admission, examination revealed the patient was afebrile with a temperature of 97.8 degrees, blood pressure 118/78, pulse 82, and respirations 18. HEENT, neck, heart, lungs, abdomen, extremity, calf, thigh, and neurologic examinations all were within normal limits. Estimated fetal weight of the infant was over 7 pounds. The cervix was 1 cm dilated, 60% effaced with membranes bulging with the vertex at -2 station. There was no pedal edema. The fetal heart tracing was reassuring and reactive. The contractions were recurring every 1-1/2 to 2 minutes. The patient was uncomfortable on admission.
HOSPITAL COURSE: Please refer to the admission dictation for the patient’s antenatal laboratory investigations and admission laboratory investigations. The patient’s postoperative hematocrit was 30.7. The patient was admitted and prepared for repeat cesarean section and sterilization. Informed consent was obtained. Brethine was administered initially to slow the contractions, as we were preparing for the cesarean section. In the afternoon, under spinal anesthesia, an uncomplicated repeat low transverse cesarean section and bilateral tubal ligation were performed. Anterior uterine surface for abdominal adhesions were lysed at delivery. A viable female infant with Apgars of 8 and 9 and cord pH of 7.32 was delivered. Birth weight was 7 pounds 8 ounces. There were no intraoperative or perioperative complications.
The patient’s postoperative course was uneventful. She was bottle-feeding. She remained afebrile with stable vital signs. She quickly returned to good ambulation, a regular diet, and moved her bowels prior to discharge. By the morning of the second postoperative day, she was anxious to go home. She was having mild pain, controlled with Percocet. Her examination revealed clear lungs, irregular heart rate and rhythm, negative breast, abdomen incision, calf, thigh, and neurologic examination. Lochia was normal. Fundus was firm. The patient had no respiratory problems during the postoperative period. She was maintained on her home medications.
CONDITION AT DISCHARGE: Stable.
DISPOSITION: Discharged to home.
DISCHARGE INSTRUCTIONS: Activity: Slowly increase as tolerated. No heavy lifting. No pushing. No straining. Strict pelvic rest. Diet: Regular.
DISCHARGE MEDICATIONS: Prenatal vitamins. The patient will continue on her Advair and her other asthma medicines as needed. Colace once or twice daily as needed. Prescriptions for Percocet 325/5 tablets, #30, no refills, one to two every four to six hours as needed for pain and ibuprofen 800 mg tablets, #30, no refills, one tablet three times daily with food as needed for pain.
FOLLOWUP: The patient will be seen in the office in one week.
Prior to discharge, the patient received routine verbal and written instructions and agreed to comply. We went over all signs and symptoms of complications. The patient knows to contact immediately should she develop any issues such as fevers, chills, heavy bleeding, neurological problems such as dizziness, weakness, blurry vision, abdominal distention with nausea and vomiting, drainage from the incision, redness, tenderness, swelling of the calves or thighs or certainly chest pain, chest pressure, shortness of breath, cough, sputum or wheeze.
