AR2728
Expert
This is the full note-scrubbed. It is very lacking in documentation, suggestions on E&M would be appreciated.
gravida III, para II, came in by ambulance due to preterm labor at 34 weeks. Suppose to go to (better equiped) hospital for delivery due to baby congenital heart problems, diverted here. 4 cm dilated, 80% effaced with presenting part high, fetal heart reactive. no regular contractions. Patient stabilized with mag sulfate of terbutaline and stadol. Patient to be transferecd for delivery to larger hospital, patient advised of possible delivery in transport.
Diag: preterm at 34 wks, baby with congenital heart
Plan: transfer within 15 minutes
gravida III, para II, came in by ambulance due to preterm labor at 34 weeks. Suppose to go to (better equiped) hospital for delivery due to baby congenital heart problems, diverted here. 4 cm dilated, 80% effaced with presenting part high, fetal heart reactive. no regular contractions. Patient stabilized with mag sulfate of terbutaline and stadol. Patient to be transferecd for delivery to larger hospital, patient advised of possible delivery in transport.
Diag: preterm at 34 wks, baby with congenital heart
Plan: transfer within 15 minutes