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Patient: Reishica Declerque DATE OF ADMISSION: 09/09/2024 DATE OF DISCHARGE: 09/11/2024 DISCHARGE DIAGNOSES: Intrauterine gestation at term History of two previous cesarean sections Delivered viable male infant Multiparity, fertility, desired sterilization PROCEDURES PERFORMED: Repeat low transverse cesarean section Bilateral tubal ligation COMPLICATIONS: None PERTINENT FINDINGS/HISTORY AND PHYSICAL: Refer to the detailed admission dictation. The patient is a 35-year-old gravida 6, now para 3-0-3-3 female, who was admitted at term for repeat cesarean section and sterilization. The patient had previous cesarean sections for labor arrest, for an infant weighing 9 pounds 12 ounces, and elective repeat. The patient strongly desired repeat cesarean section. She also wanted to have a tubal ligation and signed the appropriate consent forms. Patient is well aware of the risks, options, failure rates, and permanency of sterilization procedures. Her antenatal course was significant for development of A1 diabetes with blood sugars in excellent control, on diet only. The patient declined genetic screening because of advanced maternal age. LABORATORY INVESTIGATIONS: The patient’s admission hemoglobin was 11.1 with hematocrit of 33.4 and platelet count 196,000. Her postoperative hematocrit was 32.2. HOSPITAL COURSE: The patient was admitted on the morning of her scheduled surgery. Detailed informed consent was again obtained. Under spinal anesthesia, uncomplicated repeat low transverse cesarean section and bilateral tubal ligation were performed. A viable male infant with Apgars of 9 and 9 with birth weight of 8 pounds 6 ounces was delivered. The patient’s postoperative course was uneventful. She remained afebrile with stable vital signs. She returned quickly to good ambulation and regular diet. She had normal GI function return. Her incision healed nicely. Her lochia was light. Discharge examination revealed negative HEENT, neck, heart, lung, extremities, and abdominal examinations. CONDITION ON DISCHARGE: Stable. DISPOSITION: Discharged to home. DISCHARGE INSTRUCTIONS: ACTIVITY: Slow increase as tolerated. No heavy lifting. Strict pelvic rest. DIET: Regular. MEDICATIONS: Colace p.r.n., Tylenol p.r.n., and prenatal vitamins. The patient is breastfeeding. Prescriptions for Percocet 325/5 tablets, #30, no refills, 1 to 2 p.o. q.4-6 h. p.r.n. pain and ibuprofen 800 mg, #20, no refills, 1 p.o. q.8 h. p.r.n. pain. Follow up as an outpatient in the office in 1 week. The patient has received routine verbal instructions and agrees to comply. She knows to contact us immediately should she develop any signs or symptoms of complications such as fevers, chills, drainage from the incision, abdominal distention, nausea, vomiting, heavy vaginal bleeding, leg redness or swelling, chest pain, chest pressure, or shortness of breath. Determine the most accurate ICD-10-PCS code(s).

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