Daniel DeMarco             Focused H&P #2             OB/GYN

Chief Complaint: Sent to Triage from Antenatal Testing Unit for NST with minimal variability and no accelerations

 

History of Present Illness:

KJ is a 32yo G3P2002 at 40w5d (d,15) that was sent to OB triage from Antenatal Testing Unit for minimal variability and no accelerations. Patient endorses fetal movement and contractions. She was receiving routine prenatal care at QHC clinic. Denies passage of mucus plug, leakage of fluid, vaginal bleeding, fever, chills, nausea, vomiting, headache, edema. Patient denies complications of prior pregnancies and deliveries.

 

Obstetric History: Full Term NSVD x 2 (2015, 2016), Fetal Weight = 3062g, 3544g

Gynecologic History: None

PMH: None

Medications: Prenatal Vitamins

PSH: None

Allergies: NKDA

Family History: Father and Mother living with no known medical problems

Social History: Never smoker. No EtOH use. No illicit drug use. Admits sexual activity with male partners.

 

Review of Systems:

General : Admits weight gain. Denies fever, chills, night sweats, loss of appetite, weight loss, weakness, fatigue

Skin, Hair, Nails : Denies change in texture, excessive dryness or sweating, discolorations,

pigmentations, moles, rashes, pruritus, change in hair distribution

Head : Denies trauma, unconsciousness, coma, fracture, vertigo, headache

Eyes : Denies corrective lenses, visual disturbances, fatigue, photophobia, pruritus, lacrimation, vision changes

Ears : Denies deafness, pain, discharge, tinnitus, hearing aids

Nose/Sinuses : Denies discharge, epistaxis, rhinorrhea, congestion

Mouth/Throat : Denies bleeding gums, sore tongue, sore throat, mouth ulcers, voice changes,

dentures

Neck : Denies lumps, swelling, stiffness, decreased range of motion

Breast : Denies lumps, nipple discharge, pain

Respiratory : Denies dyspnea, shortness of breath, wheezing, cough, hemoptysis, cyanosis, orthopnea, paroxysmal nocturnal dyspnea

Cardiovascular : Denies palpitations, irregular heartbeat, edema, syncope, chest pain, known heart murmur

Gastrointestinal : Denies abdominal pain, change in appetite, intolerance to specific foods, nausea, vomiting, dysphagia, pyrosis, flatulence, eructations, diarrhea, constipation, hemorrhoids, change in stool caliber, blood in stool

Genitourinary : Denies change in frequency, urgency, hesitancy, dribbling, nocturia, polyuria,

oliguria, dysuria, change in urine color, incontinence, flank pain

Musculoskeletal : Denies joint pain, deformity, swelling, redness, arthritis

Peripheral Vascular : Denies intermittent claudication, coldness or trophic changes, varicose veins, color change, edema

Hematologic : Denies anemia, easy bruising/bleeding, lymph node enlargement, history of

DVT/PE

Endocrine : Denies polyuria, polydipsia, polyphagia, heat or cold intolerance, goiter, hirsutism

Neurologic : Denies seizures, loss of consciousness, sensory disturbances, paresthesia,

dysesthesia, hyperesthesia, ataxia, loss of strength, change in mental status, memory loss,

asymmetric weakness

Psychiatric : Denies feelings of helplessness, feelings of hopelessness, lack of interest in usual

activities, suicidal ideation, anxiety

 

Physical Exam:

Vital Signs:

BP: 124/77

Pulse: 79bpm

RR: 16 breaths/min

Temp: 36.7C

SpO2: 100%RA

Ht: 65 inches

Wt: 75.1kg

 

General Survey: Patient lying comfortably in bed. No apparent distress.

Skin: No petechiae, masses, lesions. Warm, moist.

Hair: Average quantity and distribution.

Nails: Capillary refill <2s throughout.

HEENT: Head: NC/AT. Non-tender to palpation throughout. Eyes: PERRLA. EOMs intact.

Cardiovascular: Regular rate and rhythm. S1 and S2. No murmurs, gallops, rubs.

Chest and Pulmonary: Symmetrical rise and fall of chest wall. No labored breathing, accessory muscle use. Clear to auscultation bilaterally. Right upper back minimally tender to palpation.

Abdomen: Fundal Height at the level of the xiphoid process. Soft, non-tender. No guarding, rebound tenderness.

Vaginal Exam: 2cm/L/P

Extremities and Peripheral Vascular: Upper and Lower extremities symmetrical. No edema of bilateral upper and lower extremities. Peripheral pulses 2+.

 

Cardiotocography: Baseline 145bpm, moderate variability, + acceleration, late declaration seen; Category II FHT; contractions q6min.

Fetal U/S: Vertex, Posterior Placenta, AFI = 8.2, BPP = 8/8

 

Assessment/Plan:

KJ is a 32yo G3P2002 at 40w5d (d,15) that was sent to OB triage from Antenatal Testing Unit for minimal variability and no accelerations. Admitted for induction of labor.

 

OB/GYN

#NST with minimal variability, no accelerations at 40w5d (d,15). For induction of labor.

• Bishop Score = 1 (for dilation of 1-2cm)

• Start mechanical cervical ripening with balloon catheter insertion with 80cc of normal saline
• Amniotomy after cervical ripening
• Oxytocin 2mu/min IV after amniotomy. Increase 2mu/min q20 minutes
• Patient declines spinal analgesia/epidural at this time. Continue to reassess pain and patient preferences for analgesia.
• Continuous cardiotocography
• CBC, BMP, T&S, Coags

 

DVT Prophylaxis with Intermittent Pneumatic Compression

 

/s/ Daniel DeMarco, PA-S

Physician Assistant Student