Credit: Template by Dr. Sweet
SUBJECTIVE
Pt denies any LOF, VB, ctx, dysuria, or pre-eclampsia symptoms including headaches not relieved by Tylenol, vision changes or loss of vision, RUQ pain, significant increased non-dependent edema. Reports good FM
Pt denies any LOF, VB, ctx, dysuria, or pre-eclampsia symptoms including headaches not relieved by Tylenol, vision changes or loss of vision, RUQ pain, significant increased non-dependent edema. Reports good FM
•Hx of blood transfusion: ***
•Hx of abnormal pap: ***
•Hx of STI: ***
•Hx of herpes: ***
•Hx of complications during pregnancy: ***
•Hx of complications during delivery: ***
•Hx of cervical procedures: ***
OBJECTIVE
•Gen A&Ox3, NAD
•HEENT: NCAT
•CV: RRR s1 and s2
•Resp: CTA bilaterally, no wheezing
•GI: gravid, soft, non-tender
•Ext: no edema
•Fundus:***
•Doppler FHT:***
LABS & STUDIES
•Blood type*** Rh ***, Ab*** , rubella ***, varicella ***, RPR ***, HIV ***, HBsAg ***, H/H ***/***, MCV/Plt ***/***, UA/cx ***, Pap – ***, GC/CT ***
•Blood type*** Rh ***, Ab*** , rubella ***, varicella ***, RPR ***, HIV ***, HBsAg ***, H/H ***/***, MCV/Plt ***/***, UA/cx ***, Pap – ***, GC/CT ***
•[ ] PPD/quant
•[ ] dating US
•[ ] 1st trim screen (wk 10-13)
•[ ] nuchal translucency (wk 11+2 -14)
•[ ] amniocentesis wk 14-18
•[ ] quad screen wk 15-20 (pref 16-18)
•[ ] 2nd trimester anatomy scan wk 18-20
•[ ] HGBA1C, FG
•[ ] EDS
•[ ] GBS @ 36 wks
•[ ] repeat H/H @ 24-28w
•[ ] 2 hour GTT @ 24-28w
•[ ] tdap (3rd trimester)
ASSESSMENT AND PLAN:
• @AGE@ @GP@ at @GA@ here for return OB visit.
•1. Dating: LMP *** c/w *** , EDC ***
•2. PNL: Blood type ***, antibody screen ***, rubella ***immune, HbsAg ***, HIV ***, GC/CT ***, RPR/VDRL ***, PPD ***
•3. FWB: desires screening, counseled
•4. MOD: ***
•5. BCM: ***
•6. Follow-up: ***
•Pt was seen and discussed with Attending