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
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