Chart Note Patient Name: Crandall, Josephine Room: 765B Date

Chart Note Patient Name: Crandall, Josephine Room: 765B Date of… Chart NotePatient Name: Crandall, Josephine Room: 765BDate of Note: November 10, 20xx Physician: Susan Xaver, MDHISTORY OF PRESENT ILLNESS: Patient is a 27-year-old gravida 3, para 1, Ab 1 female with last menstrual period April 7, 20xx, and estimated date of confinement of January 11, 20xx, who is currently at 31 to 32 weeks gestation with an uncomplicated pregnancy until 12:30 p.m. November 9, when she experienced spontaneous premature rupture of membranes. She was started on a terbutaline pump. However, on the morning of November 10 at approximately 4:30 a.m., she had an onset of regular uterine contractions. She presented to Methodist Hospital and had a temperature of 100.2°F. She was started on magnesium sulfate, ampicillin, and gentamicin and was transferred to Mt. Sinai Hospital. Examination prior to transfer revealed the cervix to be 3 cm dilated and completely effaced with footling breech presentation. Complete blood count prior to transfer revealed hemoglobin 11.2, hematocrit 32.8, platelets 209,000, and white count 12,000.Past obstetrical history includes spontaneous abortion x1 and vaginal delivery of a 6-pound, 3-ounce infant following an uncomplicated pregnancy.PAST MEDICAL HISTORY: Negative. GENERAL: The patient is alert, well oriented, in no acute distress. Vital signs are within normal limits, except her temperature is 100°F.ABDOMEN: Gravid with bilateral lower quadrant tenderness over the uterus to palpation. The liver is not palpable. Fetal heart tones are in the 150s and are reactive per external monitor.PELVIC: Not repeated.PRENATAL LABS: On August 10, blood type O positive, rubella immune, hepatitis B surface antigen-negative. AFP normal on September 14. Pap smear on August 12 class one.IMPRESSION:1. Intrauterine pregnancy at 31+ weeks.2. Premature rupture of membranes.3. Preterm labor.4. Amnionitis.5. Breech presentation.PLAN: We proceeded with delivery by primary cesarean section. The possible need for vertical uterine incision and implications of future pregnancies were discussed with the patient and her husband.Suzanne Xaver, MDSuzanne Xaver, MDjs:std: 11/10/20xx; t: 11/10/20xxDefine the terms below:1. intrauterine2. effaced3. gestation4. primigravida5. palpation6. breech positionReview the medical record to answer the s. 7. What happened to this patient on November 9?8. Was the patient at term when labor started?9. What was the indication for a cesarean section? 10. How many times was the patient pregnant in total?Health Science Science Nursing MMDAST 321

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