Download Neighorhood Women`s Health Specialists

Riley, Jessica, MR # 11141198
Neighborhood Women’s Health Specialists
Prenatal Clinic Record
Provider: C. Ramsey, CNM
Patient Information
Last Name
Riley
Father’s Name
Casey Holmes
Religion
None practiced
First Name
Address:
Jessica
Jessica Riley’s Apartment
Emergency Contact
Evelyn Riley (mother) Casey Holmes (boyfriend)
Age
Marital Status
18
Single
Hospital of Delivery
Neighborhood Hospital
Current Medications: none
Allergies: none
Occupation
Server
Education
GED
Newborns
Physician
Shore
Past Medical History
Item
Diabetes
O or +
Hypertension
Heart Disease
Kidney Disease
Neurologic Disease
Psychiatric
Liver Disease
Thyroid Dysfunction
Varicosities/Phlebitis
Blood Disorders
Comments:
Comments
Item
Pulmonary (TB,
Asthma)
Breast Disorders
Abnormal PAP
Uterine Anomaly
Past Surgeries
Past Hospitalizations
Trauma
Domestic Violence
Other
0
0
0
0
0
0
0
0
0
0
0 or +
Comments
0
0
0
0
0
0
0
0
0
Genetic Screening (includes patient, baby’s father, or anyone in either family)
Item
Maternal age > 35
Thalassemia Background
Neuronal Tube Defect
Congenital Heart Defect
Down Syndrome
Tay-Sachs
Sickle Cells Disease
Hemophilia
Comments:
Yes
No
X
X
X
X
X
X
X
X
Item
Muscular Dystrophy
Cystic Fibrosis
Huntington Chorea
Recurrent Pregnancy Loss or Still Birth
Mental Retardation
Maternal Metabolic Disorder
Birth defects not listed above?
Other
Yes
No
X
X
X
X
X
X
X
X
Social History
Tobacco Use
Prior to Pregnancy
Current use
½ PPD x 2 years
½ PPD
Living Arrangements
Lives with 6 month old son and boyfriend;
(father of this pregnancy) in small apartment
Alcohol Use
Prior to pregnancy
Current Use
“few”/week x 1 year
same
Safety Issues
Feels safe in home and work environment
Street Drug Use
Prior to Pregnancy
Current Use
none
none
Social Support
Close support of mother but describes that
relationship as “difficult”
Riley, Jessica, MR # 11141198
Obstetric History
Obstetric History
Past Abortions
Age at Menarche
G2P1; vaginal delivery, epidural
none
14
anesthesia; full-term infant, no
complications birth weight 6lbs 4oz.
Comments: Menstural cycles have not been regular since birth of son 6 months
ago; unable to determine LMP
Symptoms since last menstrual period
Nausea, fatigue, breast tenderness
Last Menstrual
Period
Unknown***
Menses
Monthly q 28
days; flow x 6
days light .
Use of Birth
Control
None
Infection History
No hx of Herpes, GC, Chlamydia, HPV, syphilis
Initial Physical Examination and Workup
Pre-pregnancy Weight
120 lbs (reported)
Present Weight
125 lbs
Height
64 inches
Item
Normal
Abnormal
HEENT
X
Teeth
X
Thyroid
X
Breasts
X
Lungs
X
Heart
X
Abdomen
X
Extremities
X
Skin
X
Lymph Nodes
X
Rectum
x
Comments
Ultrasound confirms pregnancy; estimated 16 weeks gestation
Item
Vulva
Vagina
Cervix
Adnexa
Uterus Size
Diagonal Conjugate
Spines
Sacrum
Subpubic Arch
Gynecoid Pelvic Type
Blood Pressure
118/72
Normal
Abnormal
X
X
X
x
15 weeks + or Reached
average
concave
normal
yes
Problems:
States she feels fatigued. States pregnancy was a shock, is getting used to idea; states she is happy. Primary concerns are financial. Believes
boyfriend will be able to help support child.
Notes:
Pelvic exam completed; Pap smear and cultures obtained; .fundal height estimated at 15 cm;
FHT 150;
UA – (neg); Serum Glucose 118; Hgb 12 g/dl; Hct: 31%
Blood drawn for syphilis/HIV/Hep B screening; ABO/RH typing (O Rh -);
Ultrasound done to confirm gestation: 16 weeks.
Plans/Teaching:
Decrease or stop smoking; avoid alcohol; diet (increase calcium & protein; minimize fast food; sodas, junk food snacks)
Take prenatal vitamins.
Go to the outpatient lab for multiple marker screen (MMS). Provider: C. Ramsey, CNM
Follow Up Visits
Weeks
Gest
20
weeks
Fundal
Ht
20 cm
FHT
150
Blood
Pressure
120/70
Weight
Urine
130
Neg
Comments and Progress Notes
−
−
−
−
MMS negative.
Reports feeling the baby move regularly.
Reports continued fatigue; is taking prenatal vitamins.
Reports smoking, but not as much; reports hard not to smoke around
boyfriend
− Reports “a few beers” since last visit“ C. Ramsey, CNM
−
Riley, Jessica, MR # 11141198
Weeks
Gest
24
weeks
Fundal
Ht
23 cm
FHT
Weight
Urine
152
Blood
Pressure
110/60
28
weeks
32
weeks
Comments and Progress Notes
132
Neg
−
−
−
−
−
−
−
27 cm
144
112/60
135
Neg
−
−
−
−
−
−
32 cm
144
122/74
137
Neg
−
−
−
−
34
weeks
34 cm
146
124/72
141
Neg
−
−
−
−
−
−
36
weeks
36 cm
144
122/74
143
Neg
−
−
−
−
−
−
−
37
weeks
36 cm
145
124/76
146
Neg
−
−
−
−
−
Reports fetal activity
Reports more energy
Still smoking, has attempted to quit; no alcohol intake since last visit.
Problems: Reports constipation; bloating sensation, hard stools
Teaching: increase fiber and fluid intake; increase activity, stool softener.
Encouraged to continue taking prenatal vitamins and healthy eating habits.
Diabetes screen and antibody screen (indirect coombs) needed; lab
requisition given with instruction to get this during next couple of weeks.
C. Ramsey, CNM
Diabetic screen negative; Coombs test negative; Rhogam administered.
Ultrasound done – growth patterns consistent with ~ 28 weeks gestation.
Reports fetal activity.
Decreased smoking to 6 cigarettes a day/ no alcohol intake since last visit.
Problems: Complains of pain and itching around anus; still constipated.
Teaching: Reduce soft drink intake; increase water intake. Encouraged to
enroll in childbirth classes. C. Ramsey, CNM
Accompanied by boyfriend (father of baby)
Reports fetal activity.
Problems: significant other stated she was doing fine; patient did not report
any problems.
Teaching: Has not enrolled in classes; information for class registration
provided. Reinforced need to abstain from alcohol and to reduce smoking
for health of infant. Asked to return in 2 weeks for 34 week visit.
C. Ramsey, CNM
Reports regular fetal activity
Bruises noted to left side of abdomen; states bumped into a table. Denies
feeling unsafe in home; denies physical abuse. Admits to occasional
abdominal cramping.
Reports no alcohol intake; smoking 4-6 cigarettes a day.
Vag exam – cervix closed.
Problems: heartburn, leg cramps, backache.
Teaching: Has not enrolled in classes; states she is not interested in this.
Reinforced nutrition; measures to reduce back discomfort. Discussed signs
of preterm labor. Discussed infant feeding; encouraged breast feeding
infant after delivery. C. Ramsey, CNM
Accompanied by boyfriend (father of baby)
Reports regular fetal activity; occasional non-painful contractions reported.
Bruises noted on arms, legs, abdomen. Both boyfriend and patient state
she has been “bumping into things” and that she is “clumsy”. Spoke with
patient in private; denies abuse. Gave information about shelter.
Vag exam – 50% effacement; cervix closed; GBS screening done.
Ultrasound – shows fetus is 5 ½ pounds; consistent with gestational age.
Problems: none reported
Teaching: Signs of labor; labor process and post-partum care. Next visit
next week. C. Ramsey, CNM
Reports regular fetal activity; increased intermittent contractions reported.
Old bruises noted on arms, legs – but none that appear new.
Vag exam – 70% effacement; cervix dilated 1-2 cm; no discharge or
bleeding; GBS culture negative.
Problems: fatigue after long day at work; tired of being pregnant.
Teaching: rest, nutrition, signs of labor, post-partum care. Next visit next
week.