Ms. P is a 32 yo black female, G₁P₂₁₀₃, LMP 8/12/97, EDC 5/19/98, NOW@40 WBD & 16 wk sonogram c/o SROM @ 10:00 pm 5/19/98 (clear), and UCs that started 5/18/98 at 11:00 pm. UCs are now 3-5 minutes apart, normal show. Pelvic exam 4/80%/0; vertex. The patient as had an unremarkable prenatal course with prenatal care beginning @ 8 wks gestation.

Prenatal Labs: O+, RI, VDRL NR, HepBSAg (-), AFP wnl, GST 100.

PMHx: denies

Meds: PNV

Allergies: NKDA.

PSurgHx: denies.

OBHx:

'92 female, 2.7 kg, 35 wks, SVD, premie A&W

'94 female, 3.7 kg, 39 wks, SVD, A&W

'95 female, 3.5 kg, 38 wks/3, SVD, A&W

No STDs

SocHx: Lives alone with husband and 3 children, denies drug use, denies alcohol or tobacco use. No transfusions.

PE:
Vital signs: BP 115/72 left lateral; P 84; R 22; T 37²
See Hollister
Fundal height: 40 cm; pelvic: 4 cm/80%/0, vertex. fern (-), nitrazine (-)

A: IUP@term in active labor.

P: Admit to L&D; expectant management.
 

OB-GYN Notes

OB-GYN

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