Subjective:

29 y/o F, G2P2002, with a PMHx of hypothyroidism and current acute blood loss anemia, s/p NSVD postpartum day #2 with no overnight events. Patient denies any complaints or concerns at this time. She states she slept well and has been tolerating her diet. She has been ambulating without any difficulty. Patient is breast and bottle feeding at this time. Patient denies fever, chills, chest pain, palpitations, shortness of breath, nausea, vomiting, abdominal pain, lower extremity pain or swelling, headache or heavy vaginal bleeding. She reports mild vaginal soreness but states the pain is adequately controlled. Patient is voiding on her own and reports to passing flatus. Patient declines circumcision for her baby boy. Patient declined MMR and Hepatitis B vaccine.

Objective:

Vital Signs:

• BP: 108/65
• Pulse: 70 bpm
• RR: 18 breaths/minute
• Temp: 98.1
• O2: 99% on room air
• Ht: 5’5”
• Wt: 194.8
• BMI: 32.37 kg/m²

Physical Exam:

• General: Alert, oriented and cooperative
• Heart: Regular rate and rhythm
• Lungs: Clear to auscultation bilaterally
• Abdomen: Soft, nontender, positive bowel sounds
• Fundus: Firm and nontender at level of the umbilicus
• Lochia: light on pad
• Extremities: Lower extremities symmetrical and nontender with no discolorations bilaterally

Labs:

• WBC 12.74, HGB 9.0, HCT 28.7
• COVID negative
• Syphilis nonreactive
• Rh positive
• HIV nonreactive
• Mumps negative, Measles positive, Rubella positive
• Hepatitis B surface antibody nonreactive

Influenza vaccination given in September 2020. TDaP received in April 2021.

Patient refused MMR and Hepatitis B vaccine today.

Assessment:

• 29 y/o F, G2P2002, s/p NSVD PPD #2 with no overnight events and no current complaints or concerns.

Plan:

• Signs and symptoms of pre-eclampsia, eclampsia and DVT discussed
• Discussed signs, symptoms and precautions of COVID-19
• Patient will be discharged today
• GYN Clinic appointment for 6/21/2021 for postpartum care