Labor and Delivery Admission Note

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History of Present Illness 
_ yo G_P_ (_) at _ and _/_ weeks EGA by _ presents to VCMC L&D with onset of regular/frequent uterine contractions that she feels are very uncomfortable every _ minutes. She states she was not having any pain or contractions prior to the start of these ones which started _. The ctx pain is located _ and feels like _.
 
Review of Systems
NEGATIVE: n/v, vaginal bleeding, vaginal discharge, HA, blurry vision, increase in swelling of extremities, CP, SOB, difficulty walking
 
Problem List/Past Medical History
Pregnant otherwise no past medical issues
Prenatal Hx: Uncomplicated
OB Hx: G_P_
Gyn Hx: Regular monthly menses when not pregnant, no hx of Gyn cancer/infx or abnormal PAP smears
 
Procedure/Surgical History
None
 
Medications
Prenatal Multivitamins oral tablet, 1.0 tab, Oral, Daily
 
Allergies
No Known Allergies
 
Social History
Has never used Tobacco, Etoh, illicit or IV drugs. Is a _ speaking. Patient reports feeling (safe/unsafe) at home.
 
Family History
No family history of pregnancy complications, high blood pressure, or DM.
 
Immunizations
Flu vax _
Tdap _
 
Physical Exam
.vitals
 
GEN: Mild distress with contractions, otherwise NAD
PSYCH: Appropriate mood and affect
CV: RRR, nl S1/S2, no MRG
RESP: CTAB, no acute distress
ABD: nl BS, soft in between contractions but firm and non-indentable uterus during ctx's that are happening every _ minutes, _/_/_ by Leopold's
EXTR: no swelling or edema in BLE
NEURO: face symmetric, MAEE, no gross neuro deficit, 2+ patella DTRs b/l, no achilles clonus b/l
SGE: _ cm/_%/_ station/_ position/_ consistency
Bedside US: _
EFM: _ Ctx q_ min, baseline FHR of _, _ variability, _ accelerations, _ decelerations, Cat _ strip
 
Lab Results
ABO/Rh: _
Ab screen: _
Hgb _
PAP _
Ur Cx: _
Rubella _
RPR _
HbsAg _
HIV _
Varicella _
Gonorrhea _
Chlamydia _
MSAFP _
1 hr GTT _
3 hr GTT _
GBS _
PPD _
 
Assessment/Plan 
_ yo G_P_ at _ and _/_ EGA likely in _ labor with uncomplicated prenatal course thus far.
 
1. _ Labor
- Admit with expectant management
- Labs: CBC with extra tube to BB for Type and Screen
- Continuous EFM 
2. Pain
- Fentanyl 100mcg IV q1hr PRN pain
- Epidural _
3. F/N
- Clear liquid diet once in active labor, LR to run at _ml/hr via IV infusion
4. PPX
- Zofran PRN nausea/vomiting
- Activity as tolerated for DVT PPX until reached 2nd stage of labor
5. GBS status _
6. Case discussed with Dr. _ who agrees with plan
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