sample l d admit note don’tforgetdateand t i m e（样本l d承认tforgetdateand注意不我m e）.docVIP

Sample LD Admit Note: Don’t forget date and TIME Chief Complaint: Contractions/ Ruptured membranes/ Elevated BP in clinic, ECT. HPI: This is a 19 year old G3 P1 Ab1 at 39 weeks gestation by LMP / Sonogram who presents for contractions / ruptured membranes / elevated BP in clinic etc. Upon evaluation, she was noted to be 4 cm dilated / to have grossly ruptured membranes / to have BP of 140/90. She was then admitted to LD for management. She reports (include all of the following whether positive or negative. You may also include other complaints if relative to chief complaint) +/- fetal movement, contractions, ruptured membranes, vaginal bleeding, headache, right upper abdominal pain, changes in vision. She desires future fertility or She desires permanent sterilization. (Does she want a tubal ligation?) Dating Criteria: (This is based on supporting or disagreeing with LMP) 1. LMP (first day of LMP) 10/16/03 -- EDC+ 2. First sonogram 1/16/04 @ 12 weeks – agrees (or redates) 3. First exam 12/16/03 @* weeks—agrees 4. Serial Exams @ 18-36 weeks; 2/04—5/04 -- agree OB History: review each pregnancy G1—1990 JPS SVD 36 wks 6 lbs PIH G2-- 1995 JPS C/S 28 wks twins 2-3 lbs PPROM G3—current GYN History: Menarche-__Regular cyclic Menses-__STD’s—Herpes, Gonorrhea, Chlamydia, Syphilis, HIV GYN surgeries Abnormal paps and treatment Family Medical History: Include parents and siblings; other pertinent Social Hx: Tobacco, ETOH, IVDA PMH: especially HTN, IDDM, Asthma Meds: Alls: latex/iodine too ROS: done in HPI PE: Vitals—use the most current; include Ht and Wt, (RR important for MG!) HEENT— Neck—thyromegaly? Heart/Lungs— CV— Breast— Abd—gravid, soft, nontender FHT’s—140’s EFW—8# Pelvis-- Cervix—4/75/-2 Cephalic/Breech Intact/Ruptured Ext—describe Edema DTR’s Current Labs: Ones ordered since admission Other Diagnostic Tests: Include sono if done this admission Prenatal Labs: Clinic labs—document all including HIV,