IDENTIFYING DATA:

• Date & Time: 4/20/23 2:27 pm
• Full Name: D. R.
• Address: ———
• DOB: –/–/94
• Location: Queens Hospital Center
• Source of information: self
• Reliability: reliable

 

CHIEF COMPLAINT: OB revisit

HISTORY OF PRESENT ILLNESS:

28 y/o G2P1001 female currently 29w5d doing well, presenting for OB revisit appointment. Patient has no complaints today. Patient desires TOLAC. EDD based on ultrasound: 7/1/23. Patient reports + fetal movement, no rupture of membrane. Denies vaginal bleeding, contractions, abnormal discharge, nausea, vomiting, headache, chest pain, blurry vision.

 

MEDICAL HISTORY:

Medications:

• Ferrous sulfate (Feratab) 325 (65FE) mg 1 tablet PO BID
• Prenatal multivitamin (prenatal plus) 27-1 mg tablet 1 tablet PO QD
• Denies OTC or herbal supplement use

Medical History:

• No significant past medical history

Immunization Hx:

• Influenza administered 2/21/23
• Declines COVID vaccine

Surgical History:

• Cesarean section x 1 – 11/09/14; Honduras; no known complications

Allergies:

• No known drug allergies
• No known food allergies
• No known environmental allerges

Family History:

• Mother: alive & well, hx hypothyroidism
• Father: alive & well, no significant PMHx
• No known family hx of cancer or cardiac disease
• 1 daughter: alive and well

Social History:

• Nonsmoker
• Denies alcohol use. Denies illicit drug use
• Occupation: Cashier
• Caffeine: Reports occasional caffeine use
• Marital history: Married
• Home situation: living in apartment with husband and daughter
• Diet: patient reports balanced diet
• Exercise: patient states she walks 10 blocks to and from work daily

OB history:

• G2P1001
• EDD: 7/1/23 based on ultrasound on 12/29/22 and 03/21/23
• Menarche: age 13
• Menstrual cycle: regular, lasts 5 days avg
• LMP: 10/08/2022
• Pregnancy outcomes:
  • #1: C/S unspecified x 1 2014 in Honduras
    • Complications: failure to progress after ROM, macrosomia – 9 lbs 8 oz,
      • denies GDMA
    • Of note: vertical skin incision noted, patient unable to get records
  • #2: current
• Blood type: O positive

GYN/Sexual history:

• Pap performed 1/23/23, cytology negative
• Sexually active with 1 male partner.
• Denies contraceptive or barrier protection use.
• No known history of STIs.

 

ROS:

• General: Denies recent weight loss, changes in appetite, weakness, fatigue, fever, chills.
• Skin, hair, nails: Denies discolorations, pigmentations, moles/rashes, changes in hair distribution or texture, pruritus.
• Head: Denies headaches, vertigo or head trauma.
• Eyes: Denies blurred vision, photophobia, or changes in vision.
• Ears: Denies pain, discharge, or changes in hearing.
• Nose/sinuses: Denies discharge, congestion, and epistaxis.
• Mouth/throat: Denies bleeding gums, sore throat, mouth ulcers, voice changes.
• Neck: Denies localized swelling/lumps or stiffness/decreased range of motion.
• Breast: Denies lumps, nipple discharge, or pain.
• Pulmonary system: Denies dyspnea, cough, wheezing, and dyspnea on exertion.
• Cardiovascular system: Denies history of HTN, chest pain, syncope, palpitations, hx of known heart murmur.
• Gastrointestinal system: Has regular bowel movements daily. Denies constipation, diarrhea, bloody stool, nausea, vomiting, and hemorrhoids.
• Genitourinary system: Admits to urinary frequency (states she has experienced this majority of pregnancy). Denies dysuria, incontinence.
• Menstrual/Obstetrical – See OB/GYN hx above. Denies vaginal bleeding or abnormal vaginal discharge.
• Nervous: Denies loss of strength, seizures, loss of consciousness.
• Musculoskeletal system: Denies muscle/joint pain, deformity or swelling, redness or arthritis.
• Peripheral vascular system: Denies intermittent claudication, peripheral edema.
• Hematological system: Denies anemia, easy bruising or bleeding, lymph node enlargement, blood transfusions, or history of DVT/PE.
• Endocrine system: Denies polydipsia, polyphagia, heat or cold intolerance, excessive sweating, hirsutism, or goiter.
• Psychiatric: Denies depression, anxiety, hx of seeing mental health professional.

 

PHYSCIAL:

General: AAO x 3. Appears stated age.

Vitals:

• BP: 107/67
• Pulse: 91
• Temp: 97.5
• Wt: 121lb
• Ht: 4’ 11”
• BMI: 24.44kg/m2
• LMP: 10/08/2022

Skin/Hair/Nails: Skin nonicteric, no lesions noted, no tattoos. Hair average quantity and distribution. No clubbing of nails, capillary refill < 2 seconds.

HEENT: Head normocephalic, atraumatic. Eyes and ears symmetrical and appropriate in size OU. No discharge or foreign bodies on external auditory canals AU. Nares patent. Good dentition, no obvious dental caries noted. No gingival hyperplasia or erythema noted. Pharynx non-erythematous, with no exudates, uvula midline.

Neck: Trachea midline. Supple; non-tender to palpation. FROM. No cervical adenopathy noted.

Thyroid: Non-tender; no palpable masses or nodules; no thyromegaly.

Cardiac: Regular rate and rhythm (RRR). S1 and S2 are distinct with no murmurs, S3 or S4. No splitting of S2 or friction rubs appreciated.

Chest: Symmetrical, no deformities, no trauma. Respirations unlabored, no use of accessory muscles noted.

Lungs: Clear to auscultation bilaterally, no adventitious sounds noted. Chest expansion and diaphragmatic excursion symmetrical.

Abdomen: Abdomen symmetric. Vertical scar noted to lower abdomen. Bowel sounds normoactive in all four quadrants. Non-tender to palpation, no guarding or rebound noted. No CVA tenderness appreciated.

Breast: Symmetric, no dimpling, no masses to palpation, nipples symmetric without discharge or lesions. No axillary nodes palpable.

Female Genitalia: Deferred.

Rectal: Deferred.

Extremities: No cyanosis, edema or deformities. No tenderness to calves. FROM.

Neurologic: Strength and sensation intact. GCS = 15.

Fetal Assessment:

• Size equals dates
• Fetal Heart Rate: 156 bpm
• Fundal Height (cm): 30 cm
• Movement: present

 

ASSESSMENT:

28-year-old G2P1001 currently 29w5d doing well here for OB follow up visit, no complaints.

PLAN:

#29-week appointment

• Administer TDAP in office 4/20
• UA
• CBC
• Syphilis screening
• 1 HR GCT 50gm

#Abnormal QuantiFERON

• Schedule CXR asap
• Pulm referral given on 4/20

#OBHx macrosomia

• Sonogram for EFW at 38 weeks

#TOLAC

• Patient desires TOLAC
• G2 form given and reviewed with patient on 4/20

#Rubeola non-immune

• MMR vaccine post-partum

Patient instructions:

• Return to clinic in 2 weeks
• See nurse for TDAP & labs
• Continue prenatal vitamins and iron
• If any vaginal bleeding, fluid loss, decreased movements, abdominal pain go to ER

 

LABS/TESTING:

CBC – 4/20/23

WBC	11.03
RBC	4.14
HGB	12.1
HCT	37.5
MCV	90.6
MCH	29.2
MCHC	32.3
RDW	13.1
PLT	344

UA – 4/20/23

Color	Yellow
Clarity	Clear
Glucose	Negative
Ketones	Negative
Specific gravity	1.015
Blood	Trace – intact
pH	7.0
Protein	Negative
Urobilinogen	0.2
Leukocyte Esterase	Negative
Bilirubin	Negative
Nitrite	Negative

1hr GCT 50gm = 106, 4/20/23

Syphilis = negative, 4/20/23

Panorama low risk, MSAFP neg, 1/23/23

Anatomy scan nml – 3/21/23