Received Mar 7, 2025
| Type | Name | Manufacturer | Dose | Lot | Route / Site |
|---|---|---|---|---|---|
| TDAP | TDAP (ADACEL) | SANOFI PASTEUR | 2 | U8389AA | IM / LA |
Patient was given the TDAP vaccine 0853 - when she went to check out she passed out at the front desk. Per witnesses, she did not fall straight to floor, pivoted and then went down to side. Vitals WNL - patient take back to room. Patient to go to triage when her mom picks her up. Patient reports good fetal movement. Left clinic at 0946 ambulatory. -OB Triage Discharge Summary Presenting Complaint: Syncopal episode at OB appointment while checking out Presenting time:1000 Discharge Diagnosis:S/P Syncopal episode Discharge time: 11:16 AM HPI: 18 y.o. female G1P0000 at 30w1d who presents to triage with the c/o gentle fall to floor following syncopal episode at OB appointment. Pt does not believe she hit her abdomen. She denies VB or LOF. She reports active fetal movement. States she feels fine Pregnancy Complicated by: Chlamydia on initial labs, TOC positive, retreated 1/29 GBS UTI on initial labs, allergy to PCN and cephalosporin, tx with nitrofurantoin per Up to Date, will need TOC Anatomy - 12/10 - 23% overall, 8%AC for 21w2d, all details visualized, will rpt with MFM or direct to US for poss IUGR, Rpt - 01/02 - 38% overall for 24w4d, 16% AC, rpt as clinically indicated, consider 3rd trim growth. Observational course/ Follow up Examination(s) Pt resting in bed in no acute distress. She reports active FM throughout monitoring/time in triage Fetal monitoring: NST: baseline 130 with moderate variability, present accelerations, NST reactive : yes TOCO: few mild irregular contractions every 10-15 minutes Plan: DC home Kick counts reviewed Reviewed importance of hydration and nutrition Labor precautions given