Monday, January 11, 2010

Doctor's Notes

I have a copy of the doctor's notes from my fourth delivery. I always love my doctor's notes to see what they have to say about me, but this one is so funny I thought I would post it on this blog.

Date of Service: 03/06/2009

HISTORY OF PRESENT ILLNESS: This a 26 year old patient of Dr. ____ who precipitously delivered a 35 week infant in her car on the way to the hospital. The patient's pregnancy has been significant for her preterm labor in the past. She received progesterone shots up until 32 weeks after which she reported that due to side effects that she was unable to tolerate them any further. She was admitted last weekend to the hospital with preterm contractions and was given a dose of steroids apparently at some point during her pregnancy. She has been experiencing contractions for the last 3 days and reports that they got stronger this evening. She got in the car with her husband to drive to the hospital for further evaluation when she delivered in the car. I received a call from the emergency room physician who reported that the patient was being transferred to labor and delivery, but the baby was fully delivered and appeared vigorous upon arrival to the emergency room.


ESTIMATED BLOOD LOSS: Unknown, although the patient has very little bleeding at this point in time.

FINDINGS: A viable male infant weighing 5 pounds 15, that is 2694 g. Apgars are unknown and unassigned by the nursery as they were not present at the time of the delivery.

LABOR AND DELIVERY: As mentioned above, the patient precipitously delivered in the car on the way to the hospital. She reports that her water broke just prior to arrival and she immediately delivered without complication. The cord was clamped and cut by the nurse from labor and delivery where the placenta was delivered by one of the nurses. The uterine fundus was immediately firm after this. I arrived and evaluated the patient. Her fundus was firm. She had very little bleeding. At that time, perineal exam revealed no obvious lacerations that required repair. There were some very superficial lacerations that did not require any suturing. The patient remained in the room in good condition, and the infant is currently in the newborn nursery being evaluated.

No comments: