Maternity
Patient Case Number: MM03- O'Malley, Denise
Patient Name: Denise O’Malley | DOB: 09-15-87 | Sex: F
Date of Service: 02-22-XX | Physician: Leslie Botch, MD

# Chief Complaint: Presents pre-operatively

# History of Present Illness:

Denise O’Malley is a 31 y/o G4 P 3003 seen and examined pre-operatively for dilation and evacuation of 16-week demise confirmed CVS. She had multiple extensive discussions and would like to proceed with D&E for evacuation of fetus.

She was seen in clinic with her FOB presented for visit on 02-19-XX to sign consents for surgery. She had misoprostol Sunday evening and Monday morning with a sip of water. She is a Jehovah’s witness and declines all blood products, though she accepts RhIG and cell saver. She desires POC to be sent to funeral home for cremation. She still has to choose the specific home. She would like handprints and foot prints taken at time of D&E. I asked her to relay that to Dr. Stevens but it may difficult as the hand and feet are only 1-1.6 cm. She asked about the participation of residents including Dr. Silver, and I explained this and answered all of her questions to her satisfaction. Today, pt denies any chest pain, palpitations, headaches, lightheadedness, shortness of breath, cough, nausea, vomiting, diarrhea, constipation, fever, or chills.

Review of Systems: as above and otherwise negative

# Ultrasound General results:

Incomplete spontaneous abortion, 16w Singleton intrauterine pregnancy is identified. Presentation is breech.

Placenta is posterior with no previa. No heart rate due to fetal demise.

Amniotic fluid is normal.

Fetal Measurements | Mean Age | Mean
BIPARIETAL DIAMETER (BDP) | 15w0d | 2.79cm
Head Circumference (HC) | 15w6d | 11.75cm
Abdominal Circumference (AC) | 15w5d | 9.65cm
Femur (FL) | 14w1d | 1.40cm
Humerus (HL) | 14w4d | 1.61cm
Clinical Mean Age | 16w6d | EDD 7-27-XX
Ultrasound Mean Age | 15w1d+/- 10d | EDD 8-8-XX
EFW |  | 113 +/- 16gm = 0lbs 4oz

# Medical History: No past medical history on file

# Surgical History: None

# Allergies: NKDA

# Medications: Misoprostol 200mcg-take two pills at night before your surgery and two pills in the morning of surgery, Prenatal vitamins, Vitamin D3 400U qd

# Physical Examination:

# General: No acute distress. Well nourished. Alert and oriented x 3.

# Heart: S1, S2 present, RRR, no murmurs, rubs, or gallops

# Lungs: CTAB. No wheezes, rales, or rhonchi.

# Abdomen: Soft. Nontender. No rebound or guarding.

# Impression:

Denise O’Malley is a 31 y/o G4P3003 with 16-week demise, fetus with trisomy 13.

# PLAN:

Dilation and evacuation under ultrasound guidance CBC, Type and screen

Patient declines blood products SCDs for OVT ppx

200mg Doxycyline PO pre-op

Misoprostol, methylergonovine, Carbaprost, Oxytocin on hold NPO for surgery

Plasmalyte at 125 ml/hr

# Electronically Signed By: Leslie Botch, MD

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