Report 1 Clara Raoul #CR040302CN - At

Report 1
Name: Clara Raoul
#040302
PROBLEM #1 Term gestation.
SUBJECTIVE
Patient in active labor after induction with Pitocin.
OBJECTIVE
Vertex presentation. Cervix: 5 cm dilatation and 50% effacement. Station: -3. No decelerations
for the past 2 hours of labor. Amniocentesis: L/S ratio mature.
ASSESSMENT
Adequate descent and dilatation after Pitocin induction. Fetal pulmonic maturity. No further
decelerations.
PLAN
Normal vaginal delivery.
____________________________________
Sansuk Sudsai, MD
D:
T:
SS:
Footnotes
1
OK to use a numeral following a colon when expressing a measurement or a test result.
To indicate station, use the symbol for minus. Rule 10.
3
“Pit” is slang. Edit to the full term. Rule 61.
2
4
Doctor spells this term for you. Always double check the doctor’s spelling.
1
2
3
4