Patient Name: Green, Michelle

DOB: 4/17/86
MRN: 987573

Time Provider Notes
0800 Mary Rolland, RN Patient AAOx4, has had great prenatal care, wants no pain medicine for her delivery and she wants to breastfeed. She is a G1P0 at 41 1/7 weeks gestation. Yesterday she was seen in the office and only had about 200ml of amniotic fluid around the fetus so she was admitted last night around 7pm for induction of labor. She got a foley bulb around 9pm and Pitocin started at 7am this morning, slowly increasing the dose up to 10units currently to increase her contractions. Patient contracting regularly every 2-3 minutes with strong contractions lasting about 45 seconds each. Her water broke an hour ago and fluid was clear yellow. Fetal heart rate baseline rate of 130 beats per minute, moderate variability, some accelerations but no decelerations. Vaginal exam shows cervix is 8-9cm, 100% effaced, and the fetal head is at +1 station.
Status Time Ordering Physician Order
Active 0800 Johhanna Bach ER PA BMP, CBC, Coagulation labs once
Active 0800 Johhanna Bach ER PA C difficule stool sample
Active 0800 Johhanna Bach ER PA Urinalysis
diphenhydramine/Benadryl 50mg PO QHS PRN Sleep

Novolin 70/30 insulin 15 units SubQ BID (0800 and 1700)

IV 0.9NSS 2L ordered

Time 0800
Heart Rate 110
Blood Pressure 95/70
Respiratory Rate 20
Pulse Ox 97% on Room Air
Temperature 101.4 F Oral
Pain 6/10

Basic Metabolic Panel

Lab Result Tested Value Normal Value Range
Glucose 86 70-100
BUN 15 5-20
Creatinine 1.4 0.5-1.5
Sodium 134 135-145
Potassium 3.4 3.5-5.0
Chloride 94 95-105
Calcium 10 9-11

Complete Blood Count with Diff

Lab Result Tested Value Normal Value Range
WBC 11 4.8-10.8
RBC 5.1 4.7-6.1
HGB 12.2 12.6-17.4
HCT 40 37-51
Platelets 399 130-400

Coagulation Studies

Lab Result Tested Value Normal Value Range
PT 10.2 7.6-10.6
PTT 30 26-38
INR 1.0 0.8-1.2
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