OB INITIAL COMPREHENSIVE NOTE

Identifying Data:

Full Name: Ms. M

Address: Brooklyn, NY

Date of Birth: March 23, 1998

Clinic Visit: February 19, 2020

Location: Woodhull Women Health Services, NY

Nationality: Hispanic

Marital status: married

Source of Information: Self

Source of Referral: self

 

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

 HPI:

21 years old reliable female G1P0 LMP 11/20/2019 EGA – 13 0/7 weeks gestation EDD – 8/26/2020 came to the clinic for an initial OB visit. The patient and partner are really happy with the pregnancy. Pt reports mild fatigue, weakness, nausea and few vomiting episodes in the morning since the beginning of pregnancy. Also, Pt shares about decrease appetite and mild weight loss as pre-pregnancy weight 115 and current weight is 112 pounds. However, the Patient denies HTN, chest pain, palpitations, shortness of breath, abdominal pain, excessive vomiting, cysts, fibroids vaginal bleeding, vaginal discharge or urinary symptoms.

Past Medical History: none

Immunizations – up to date. Flu vaccine in September 1st 2019

Screening tests and results – none

 Past Surgical History: None. Denies transfusions or injuries.

 Medications: none

Allergies:

Denies NKDA

Family History:

Maternal grandmother- alive with Diabetes

Maternal Grandfather- alive with Diabetes

Mother – alive and healthy

Father – alive and healthy

Social History:

Ms. S is a young healthy female who is living with her partner currently

Habits –Denies smoking, drinking alcohol, or illicit drug use

Travel – she recently did not travel.

Exercise – She is not active.

Review of Systems:

General – Admits generalized weakness/fatigue, loss of appetite, and recent weight loss. Denies fever, chills, night sweats.

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

Head –Denies headaches, vertigo or head trauma.

Eyes –denies lacrimation, visual disturbances (diplopia), pruritis, and photophobia.

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

Nose/sinuses – Denies obstruction or epistaxis.

Mouth/throat –Denies bleeding gums, sore tough, sore throat, mouth ulcers.

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

Breast – Denies lumps, nipple discharge, or pain.

Pulmonary system – denies dyspnea, dyspnea on exertion, cough, hemoptysis, cyanosis, orthopnea, or paroxysmal nocturnal dyspnea (PND).

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

Gastrointestinal system – Admits of nausea and mild vomiting  but denies dysphagia, pyrosis, flatulence, eructation, change in appetite,, abdominal pain, diarrhea, jaundice, hemorrhoids, rectal bleeding, blood in stool or constipation.

Genitourinary system – denies urinary frequency, urgency, nocturia, polyuria, oliguria, dysuria, incontinence, or flank pain.

Sexual Hx – She is currently sexually active with her male partner who she has been with for past five years. Denies history of sexually transmitted diseases.

Menstrual/Obstetrical – G1P0. Menarche age 12. LMP 11/20/2019. Denies vaginal bleeding

Nervous –Denies seizures, headache, loss of consciousness, sensory disturbances, ataxia, loss of strength, change in cognition / mental status / memory, or weakness.

Musculoskeletal system –Denies muscle pain, joint pain, deformity or swelling, redness.

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

Hematological system – Denies anemia, blood transfusions, history of DVT/PE, easy bruising or bleeding, lymph node enlargement.

Endocrine system – Denies heat or cold intolerance, and excessive sweating, polyphagia, hirsutism, or goiter

Psychiatric – denies depression/sadness, anxiety, OCD or ever seeing a mental health professional.

Physical

General: 21 years old well-developed female, A/O x 3, facial features symmetric. Pt is small build, height and weight within normal range, appears to be reported age, good posture, and good hygiene. Pt appears clean, well-groomed, speech clear, cooperative, and appear to be in physical  distress.

Vital Signs:

BP: R L sitting 120/ 70

R: 17/min unlabored

P: 98, regular

T: 98.4 degrees F (oral)

O2 Sat: 100% Room air

Height 60 inches Weight 112 lbs. BMI: 21.87

Skin/Hair/Nails

• Nails: no sign of clubbing, cyanosis, koilonychia, paronychia. capillary refill <2 seconds throughout.
• Skin: warm & moist and smooth to touch, good turgor. Nonicteric, no evidence of hypo or hyper pigmentation, erythema, mass, lesions, scars or tattoos.
• Hair: good quantity, silky and evenly distributed without any sign of alopecia, no nits or seborrhea noted.

Head: normocephalic, atraumatic, no specific facies.

Eyes: Symmetrical OU; no evidence of strabismus, exophthalmos, ectropion, entropion, ptosis, edema, inflammation, crusting, discharge; Lacrimal gland does not seem enlarged.

Ears: Symmetrical, no evidence of mass, lesion, erythema, inflammation, ear canal atresia.

Nose: Symmetrical, no evidence of mass, lesion, deformities, erythema, inflammation.

Mouth & pharynx:

• Lips – Pink, moist; no evidence of cyanosis or lesions.

 

Neck, trachea, thyroid:

• Neck – Trachea midline. No masses; lesions; scars

THORAX & LUNGS:

Chest – Symmetrical chest wall movement, no evidence of deformities, kyphosis, scoliosis, masses, lesions, cyanosis. no evidence of trauma. Lat to AP diameter 2:1 no evidence of barrel chest.

Heart: regular rate and rhythm (RRR); S1 and S2 are normal. There are no murmurs, S3, S4, splitting of heart sounds, friction rubs or other extra sounds.

Lungs – clear to auscultation and no evidence of adventitious sounds.

Abdomen: Flat / symmetrical / no evidence of scars, striae, caput medusae or abnormal pulsations. Bowel sounds in all four quadrant; Soft, non-tender; no masses, no organomegaly

Breasts:  normal appearance, symmetric, no dimpling, no masses or nipples discharge. No axillary nodes palpable

Female genitalia: cervix normal in appearance, external genitalia normal, no adnexal masses or tenderness, no cervical motion tenderness, vagina normal without discharge and gravid, a non-tender uterus with the fundal height of 10cm, FHR – 165 bpm.

Musculoskeletal system: no ecchymosis/atrophy / or deformities in bilateral upper and lower extremities. Active range of motion in upper and lower extremities bilaterally.

Neurologic:

Mental Status: Alert and oriented to person, place and time. Memory and attention are intact. Receptive and expressive abilities intact. Thought coherent.

Assessment:

21 years old female G1P0 here at 13w0d by LMP11/20/2019 for initial OB visit. Bedside doppler confirms a fetal heart rate of 165 bpm, no known risk factor, negative family history for congenital abnormalities. The patient offers no complaints and is happy with pregnancy.  In this visit, Urine Analysis was reviewed.

Problem list: 13 weeks of gestational pregnancy

Plan:

1. Order the 1st trimester labs

• • Urine Culture
  • CBC and differential
  • Hemoglobin Electrophoresis
  • Rubella Antibody
  • Mumps
  • Varicella Antibody
  • Syphilis Ab RPR titer
  • Hepatitis antigen and antibody
  • HIV AG/AB Screen By CMIA
  • Chlamydia/ G.C. Amplification
  • Lead, Blood
  • QuantiFERON Plus TB
  • TSH
  • Hemoglobin A1C
  • Type and Screen

2. Schedule an initial prenatal sonogram
3. Discuss the benefits of breastfeeding and the patient expresses hopes to breastfeed the newborn.
4. The importance of a healthy diet, continuous intake of prenatal vitamins, moderate activity, and adequate rest was discussed with the patients
5. Pt was schedule to came 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
6. Referrals: WIC, Dental, Nutrition, Breastfeeding and Childbirth Classes.