DISCHARGE SUMMARY / HOSPITAL

ABSTRACT
PATIENT
NAME:
ADMISSION
#

Enriquez, Rosselle Vergara

DATE
ADMITTED:

3531

SEX:
4/8/2016

DICHARGE
DATE:

AGE:

4/10/2016

ROOM:

20y.o
322-B

Gravida 2 Para 2 (2002) Pregnancy uterine 35 3/7 weeks, cephalic, delivered spontaneously to a live term
baby boy BW 2.9kg AS 8,9 BS 38-40 weeks, AGA
ADMITTING DIAGNOSIS:
Gravida 2 Para 2 (2002) Pregnancy uterine 35 3/7 weeks, cephalic in preterm labor
FINAL DIAGNOSIS:

CHIEF COMPLAINT:

Bloody show

(First Trimester: Patient had usual signs and symptoms of pregnancy such as nausea and vomiting.
Pregnancy test was done and revealed positive after 1 month cessation of menstruation. PNCU was
started and she was given prenatal medications. Patient denies history of maternal illness.
Second Trimester: Quickening was felt on the 5th month of pregnancy. PNCU and intake of prenatal medications were continued.
Third Trimester: PNCU was continued. Patient was apparently well until few hours prior, patient had labor pains. Patient then sought
consult hence admitted.
CLINICAL HISTORY :

LABORATORY FINDINGS:
URINE

X-RAY
FINDINGS:
ULTRASOUND RESULT:
OPERATION
PERFORMED:
HISTOPATH
FINDINGS:

STOOL

BLOOD

CHEMISTRY

Normal spontaneous delivery with median episiotomy and repair

Patient was admitted and put on NPO. She was hooked to IVF: D5LR 1L x 8. Uterine contractions were
monitored closely. She had stable vital signs. Baseline CTG was done which revealed reassuring
result. She was given Nubain 1amp thur IV, oxytocin 10units incorporated to IVF. She eventually
COURSE IN THE
delivered via normal spontaneous delivery to a live term baby boy. Dormicum 1amp and methergine
1amp via slow IV push. She was then transferred to recovery room where vital signs were monitored.
WARD:
After few hours, she was sent back to room. Diet was changed to diet as tolerated. The following
medications were given: Amoxicillin 500mg/tab 3x a day and Mefenamic Acid 500mg/tab every
6hours.
On the 2nd hospital day, she was encouraged breastfeeding exclusively and early ambulation. She was advised to go home and home
medications were instructed.

DISPOSITION: (include home medications, special instructions, and follow up)

Encouraged Exclusive breastfeeding and daily perenial hygiene

THM: Amoxicillin 500mg/tab 1 tab 3x a day for 7days, Mefenamic acid 500mg/tab 1 tab every 6hours as needed for pain.
Follow-up April 18, 2016

PGI Gian Rabago

NAME & SIGNATURE

Dr. Delphine Chua

ATTENDING PHYSICIAN
License
#

NAME & SIGNATURE

RESIDENT-IN-CHARGE