Full H & P 2 – OB/GYN

Identifying Data:

 

Full Name: Ms. P

DOB (Age):  xx/xx/1988 (32 y.o.)

Gender: Female

Date & Time: Jan. 08, 2021

Location: Woodhull, Brooklyn

Source of information: Self

Reliability: Reliable

 

Chief Complain: “I am here for my first OB visit”

HPI:

A 32 Y/O female G2P1001, LMP 11/16/2020 and EGA 7wk4d, gestation EDD 08/23/2021 came to the clinic for initial OB visit. Patient and her husband are really happy with the pregnancy. Patient states mild fatigue, weakness, morning nausea and few vomiting episodes, since the beginning of pregnancy. Patient also reports she had “hard time” with previous labor/delivery and wants c/s. Explained to patient that we do not do c/s because she is afraid of labor. Patient verbalizes understand. Patient denies HTN, SOB, chest pain, palpitation, abdominal pain, excessive vomiting, cysts, fibroids, vaginal bleeding, vaginal discharge, or any urinary symptoms.

Past Medical History:

• Past medical illness – Denies
• Childhood illnesses – Denies
• Immunization – Up to date; last flu vaccine yearly

Past Surgical History:

• Denies

Home Medications:

• None

Allergies:

• Pt has no known allergies

Family history:

• Mother – Alive and healthy
• Father – Alive, HTN

Social History:

Married young healthy female, living with her husband in an apartment. Denies drinking alcohol/caffeine, smoking, or illicit drug use. Denies recent traveling history. Regular diet. Routine walking. Denies sleeping problems. Sexually active, denies any hx of STD

Review of systems:

General –No appreciable disease.  Patient denies generalized weakness, recent weight loss or weight gain, loss of appetite, or night sweats.

Skin, hair, nails – Denies changes in texture, excessive dryness or sweating, discolorations, pigmentations, or changes in hair distribution.

Head – Denies headaches, vertigo, head trauma, unconsciousness, coma, or fracture.

Eyes –Denies diplopia, fatigue with use of eyes, scotoma, halos, lacrimation, photophobia, pruritus. Last eye exam: none.

Ears – Denies deafness, pain, discharge, tinnitus or use of hearing aids.

Nose/sinuses – Denies discharge, epistaxis, or obstruction.

Mouth and throat – Denies bleeding gums, sore tongue, sore throat, mouth ulcers, voice changes or use dentures.

Neck – Denies localized swelling/lumps or stiffness/decreased range of motion.

Breast – Denies lumps, nipple discharge, or pain.

Pulmonary system – Denies wheezing, dyspnea, cough, hemoptysis, cyanosis, orthopnea, or paroxysmal nocturnal dyspnea (PND).

Cardiovascular system – Denies HTN, chest pain, palpitation, irregular heartbeat, edema/swelling of ankles or feet, syncope or known heart murmur.

Gastrointestinal system – Regular bowel movements daily. Denies nausea, vomiting, loss appetites, intolerance to specific foods, dysphagia, pyrosis, unusual flatulence or eructations, diarrhea, jaundice, hemorrhoids, constipation, rectal bleeding, or blood in stool.

Genitourinary system – Denies urinary frequency, polyuria, nocturia, oliguria, dysuria, incontinence, awakening at night to urinate or flank pain.

Sexual History: States she is currently sexually active with her husband. Denies history of sexually transmitted diseases.

Menstrual/Obstetrical – G2P1001. Menarche age 13. LMP 11/16/2020. Denies vaginal bleeding

• NSVD x 1 – Woodhull – 2018 – no complications 7lb4oz

Nervous system – Denies headaches, dizziness, seizures, loss of consciousness, sensory disturbances, ataxia, or change in cognition/mental status/memory.

Musculoskeletal system –Denies muscle pain, or deformity.  

Peripheral vascular system – Denies intermittent claudication, coldness or trophic changes, varicose veins.

Hematologic system – Denies transfusion, easy bruising or bleeding, lymph node enlargement or history of DVT/PE

Endocrine system – Denies polyuria, polydipsia, polyphagia, heat or cold intolerance, excessive sweating, hirsutism, or goiter.

Psychiatric – Denies depression, sadness, anxiety, obsessive, or any experience of seeing a mental health professional.

Physical Examination:

Vital Signs:

 

BP 119/72, sitting, right arm

HR 92 bpm, RRR

O2 Sat: 100%

RR 18 breaths per minute, regular

T 98.2 oral

Ht 5’1’’    Wt 130 lbs     BMI  24.16

 

General: Patient is a 32-year-old female, A&O x 3. Well-developed and good posture. Well dressed, groomed, and nourished. No apparent distress.

Skin: warm & dry, good turgor. No scar, increase or loss in pigmentation, nonicteric

Nail: no clubbing. Capillary refill < 2 seconds throughout. Nails are trim

Hair: average quantity and soft of hair, evenly distribution, no signs of lice, nits, no seborrhea.

Head: eyes and ears aligned, normocephalic, atraumatic, non-tender to palpation throughout, except left frontal area. no trauma, no specific facies.

Eye: Symmetrical OU; no redness, no strabismus, exophthalmos or ptosis; sclera white; conjunctiva & cornea clear. Visual fields full OU. PERRL, EOMs full with no nystagmus.

Ears: Symmetrical, no evidence of mass, lesion, erythema, inflammation, ear canal atresia. Non tender to palpation. Auditory Acuity: whisper test, intact to whispered voice AU.

Nose/Sinuses:

Nose – Symmetrical, no evidence of mass, lesion, deformities, erythema, inflammation. Non-tender to palpation and no step-off. no evidence of nasal obstruction

Sinuses – Non tender to palpation

Mouth/Throat:

Pink and well hydrated lip, gingivae, tongue, mucosa, and palate. No masses, lesions, erythema, exudate or discharge noted. Good dentition. No obvious dental caries noted. Non-tender to palpation. Uvula pink, no edema, deviation.

Neck/Thyroid:

Trachea midline. 2+ Carotid pulses. No masses, lesions, scars, pulsations noted. No stridor, thrills, bruits noted bilaterally. No palpable adenopathy noted. Non-tender to palpation, no thyromegaly noted.

Thorax and Lungs:

Chest – Symmetrical, no deformities, no evidence trauma.   Respirations unlabored, no paradoxic respirations or use of accessory muscles noted.  Lat to AP diameter 2:1. Non-tender to palpation.

Lungs – Clear to auscultation. No adventitious sounds. No stridor, respiratory distress.

Breast:

Normal appearance, symmetric, no dimpling, no masses or nipples discharge. No axillary nodes palpable.

Cardiovascular:

Regular rate and rhythm (RRR); S1, S2 noted; No gallops, S3 or S4. No JVD. Carotid pulse 2+ bilaterally without bruits.

Abdomen:

Soft, non-distended, symmetrical, no evidence of scars, striae, caput medusae or abnormal pulsations. BS present in all 4 quadrants. No bruits noted over aortic/renal/iliac/femoral arteries. Tympany to percussion throughout. Non-tender to percussion or to light/deep palpation. No evidence of organomegaly. No masses noted. No evidence of guarding or rebound tenderness. No CVAT noted bilaterally.

Female genitalia: external genitalia normal, cervix normal in appearance, no adnexal masses or tenderness, no cervical motion tenderness, vagina normal without discharge and gravid, non-tender uterus. xxx as chaperone

Peripheral Vascular System: Skin normal in color and warm to touch upper and lower extremities bilaterally.  No calf tenderness bilaterally. No palpable cords or varicose veins bilaterally.

Neurological:

Mental Status: Alert and oriented to person, place and time. Memory and attention intact. Receptive and expressive abilities intact. Thought coherent. No dysarthria, dysphonia or aphasia noted.

Musculoskeletal: No erythema/ecchymosis/atrophy/deformities in bilateral upper and lower extremities. No crepitus noted throughout. No evidence of spinal deformities. FROM of all upper and lower extremities.  No evidence of spinal deformities.

Assessment:

A 32 Y/O female G2P1001, LMP 11/16/2020 and EGA 7wk4d came in for initial OB visit. Bedside doppler confirms IUP, and too early for FHR, no known risk factor, negative family history for congenital abnormalities. Patient offers no complaints and is happy with pregnancy.  In this visit, Urine Analysis was reviewed.

Problem list: 7 weeks of gestational pregnancy

Plan:

1. Order the 1st trimester labs
   1. Urine Culture
   2. CBC and differential
   3. Hemoglobin Electrophoresis
   4. Rubella Antibody
   5. Mumps
   6. Varicella Antibody
   7. Syphilis Ab RPR titer
   8. Hepatitis antigen and antibody
   9. HIV AG/AB Screen By CMIA
   10. Chlamydia/ G.C. Amplification
   11. Lead, Blood
   12. QuantiFERON Plus TB
   13. TSH
   14. Hemoglobin A1C
   15. Type and Screen
   16. Schedule an initial prenatal sonogram
2. Discuss the benefits of breastfeeding and the patient expresses hopes to breastfeed the newborn.
3. The importance of healthy diet, continuous intake of prenatal vitamins, iron, moderate activity, and adequate rest was discussed with the patients
4. Pt was scheduled to come back to the clinic after 4 weeks but was informed to come to ER if ever experience severe abdominal pain, vaginal bleeding or any other extreme symptoms.
5. Referrals: WIC, Dental, Nutrition, Breastfeeding and Childbirth Classes.