Prenatal

Age: ‍ years old

Gender: female



HISTORY:

Presents for a routine pregnancy follow-up

Gestational Age: ‍ weeks ‍/7, last menstrual period on ‍

G‍01234 P‍01234 A‍01234



Current symptoms: ‍none

‍vaginal bleeding

‍leaking of fluids

‍contractions

fetal movements: ‍feltreducednot felt anymore ‍not felt yet

‍nausea

‍vomiting, ‍ episodes ‍per day, ‍, ‍hematemesis

‍fatigue

‍heartburn

‍dysuria

‍frequent urination

‍abdominal pain, ‍diffuse, ‍dull, ‍mild

‍shortness of breath

‍swelling

‍headache, ‍diffuse, ‍persistentintermittent, ‍pressurethrobbing, ‍mild

‍insomnia

‍depression



Medications: ‍ ‍none, ‍folic acid

Past medical history: ‍ ‍none

Rhesus status: ‍-+



Growth:

Weight: ‍ ‍kglbs

Fundal height: ‍ cm

Fetal heart rate: ‍ bpm



Ultrasound:

Location of pregnancy: ‍intrauterineectopic

Gestational age: ‍ weeks + ‍ days

Fetal presentation: ‍cephalicbreechtransverse

Placenta: ‍anteriorposteriorfundallow lyingprevia

Fetal anatomy: ‍normalanomalies noted: not performed



Vaccinations:

Rubella: ‍immunenon-immuneunknown

Influenza: ‍up-to-dateincompleteunvaccinated

Covid: ‍up-to-dateincompleteunvaccinated

Tdap: ‍up-to-dateincompleteunvaccinated





EXAM:

General appearance: ‍well-appearing, ‍apparent distress

Vital signs: ‍normal, BP ‍, HR ‍, RR ‍, SpO2 ‍ %, Temp ‍°

Metrics: weight: ‍ ‍kglbs, height: ‍ cm, waist: ‍ cm, BMI: ‍

Neck: ‍normal, ‍lymphadenopathy, ‍, c-spine ‍

Heart: ‍RRR, ‍MRG, ‍normal S1 and S2

Lungs: ‍clear bilaterally, ‍abnormal sounds, ‍retractions

Abdomen: ‍soft, ‍non-tender ‍, ‍non-distended, ‍guarding, bowel sounds ‍normal, ‍, ‍CVA tenderness ‍

Pelvic: external genitalia ‍normal, vagina ‍normal, cervix ‍normal, uterus ‍normal, adnexa ‍normal, ‍cervical motion tenderness

Mental status: ‍alert, ‍oriented, speech ‍clear, mood ‍normal, thought ‍organized, ‍suicidal ideation, judgment ‍good





ASSESSMENT:

‍Normal pregnancy ‍likelysuspectedpossible, ‍well-managed

DDx: normal pregnancy, gestational diabetes, obesity, preeclampsia, gestational hypertension, preterm labor, placenta previa, placental abruption, intrauterine growth restriction, multiple gestation, infections, anemia, thyroid disorders, autoimmune disorders, venous thromboembolism, fetal anomalies, oligohydramnios, polyhydramnios, uterine abnormalities, cervical insufficiency





PLAN:

Investigations:

- Blood work: ‍CBC, ‍glucose, ‍TSH, ‍HbA1c, ‍blood type and Rh, ‍antibody screen, ‍rubella immunity, ‍hepatitis B, ‍syphilis, ‍HIV

- Glucose tolerance test

- Urinalysis

- Urine culture

- Ultrasound: ‍dating, ‍growth

- Genetic screening: ‍first trimester screening, ‍cell-free DNA, ‍amniocentesis, ‍chorionic villus sampling

Treatments:

- ‍Prenatal vitamins

- ‍Anti-emetics

- ‍Analgesics

- ‍Antacids

- Dietary counseling: ‍balanced diet, ‍weight gain, ‍caffeine restriction, ‍alcohol avoidance

- Smoking cessation counseling

- Immunizations: ‍influenza, ‍Tdap

Further care:

- Referral to obstetrician

- Referral to social worker

- Follow-up in ‍ ‍weeks

- Return if symptoms worsen or if new symptoms develop