Prenatal Note
RD, 36 y/o F
9/4/12, 9:00am
Shinglehouse Family Practice
Candy Hull PA-S, Eric Schreiber PA-C
CHIEF COMPLAINT: I have not had a period for 3 months and took an at home pregnancy test
and it was positive.
S:
36 y/o G4P3 presents with amenorrhea for past 3 months and nausea in the morning for the past
2 weeks. She usually has a regular menstrual cycle q 28 days. Nausea usually lasts for a few
minutes and goes away without vomiting. She has not felt fetal movement at this time. She has 3
other children that were all born natural births without defect or disease.
Medication:
Effexor 150mg qd
Ativan 1m qd PRN
Allergies:
PCN (anaphylactic)
PMH: Has been married for 16 years, monogamous relationship. Hospitalized for each child and
for anaphylactic reaction to PCN at 6 y/o. Denies any recent trauma or surgeries. Gets influenza
vaccine yearly. No known chronic diseases. 0/10 pain.
FH: only child, no siblings
Parents both alive (father – 62 y/o, mother – 60 y/o) without chronic disease.
PGM at 68 y/o and PGF at 70 y/o died in MVA. No known chronic disease.
MGM died at 80 y/o from CAD, MGF 86 y/o alive with Alzheimer’s, HTN, atherosclerosis
Denies any history of CA, stroke, asthma, arthritis, DM, bleeding disorders, tuberculosis,
epilepsy, mental illness.
SH: Lives on farm with husband and 3 children: 13 y/o F, 11 y/o M, 9 y/o M. Parents and MGF
live on farm as well, very close family. She is active on the farm and around the house. Denies
any hx of smoking, drinking, or drug abuse.
ROS:
General: denies any recent weight changes, weakness, fever, night sweats
Skin: denies any acne, eczema, psoriasis
HEENT: denies any loss of consciousness, headaches, dizziness, vision changes, watery eyes,
tinnitus, hearing loss, recurrent ear infections, recurrent sinusitis, allergies, rhinorrhea, epistaxis,
sinus tenderness, sore throat
CV: no history of AAA, murmur, DOE, edema, palpitations, chest pain
Respiratory: denies ever having episode of SOB, asthma, sleep apnea, wheezing, cough, snoring,
pneumonia, anaphylactic reaction
GI: denies any constipation, abdominal pain, diarrhea, reflux, heartburn
GU: denies any enuresis, burning, pain
Vaginal: See HPI
Vascular: denies any peripheral edema, anemia, bleeding problems, bruising, petechiae
MS: denies any fractures, muscle aches, pain, ROM limitations
Neuro: denies any hx of hyperactivity/ADHD, autism, developmental delays
Endocrine: denies any heat/cold intolerance, diaphoresis, polyuria, polydipsia, polyphagia
Psych: denies any anxiety, mood swings, depression, schizophrenia
ID: no known recent exposures/travel
O:
Vitals
Height: 5 ft 8 in/173 cm, Weight: 152 lbs 0 oz / 69 kg, BSA: 1.82 m2, BMI: 23.1 kg/m2
T: 98 F / 36.7 C (Tympanic), Pulse: 120, RR: 18, BP: 132/80 (Sitting, Left Arm)
General appearance: WDWN, NAD
Skin: No café au lait spots, dry patches, ecchymosis, hemangiomata, nevi, rash, acne
HEENT: Normocephalic/atraumatic, no conjunctivitis, discharge, nystagmus, strabismus, AV
nicking. TM intact, no bulging, tenderness, erythema, fluid, cerumen obstruction, scarring.
Nostrils patent, no drainage or obstruction. Oral mucous membranes moist without ulceration,
lesions, white lacy patterns or patches. Oropharynx and tonsils without erythema, exudate,
postnasal drainage, thrush, hypertrophy, peritonsillar abscess. Neck supple without adenopathy
or tenderness. Thyroid not enlarged, firm, or nodular
CV: No chest wall deformities visualized. RRR, S1 and S2. No murmur, S3 or S4, rub or click.
PMI 5th ICS midclavicular line
Respiratory: Breathing unlabored, no retractions or accessory muscle use. No crackles,
wheezing, rhonchi on auscultation. No dullness or hyperresonance to percussion. Tactile fremitus
present, not decreased
GI: Negative for tenderness or distension. Bowel sounds heard all 4 quadrants without bruit.
Abdomen soft without mass, rigidity, organomegaly, hernia. Tympanic percussion heard over
epigastric region, dull percussion heard over liver
GU: No rashes, ulcers, scars, nodules, induration, discharge, or mass
Breasts: no masses, adenopathy, rashes, dimpling
Vascular: Symmetrical posterior tibial and dorsalis pedis pulses (2+, 0-4), radial pulse 2+ bilat
MS: Negative for scoliosis, asymmetry, kyphosis, crepitus, deformity, mass, tenderness. No
decreased ROM. 100% full flexion, extension, lateral bending, rotation.
Neuro: Motor grossly intact, sensory grossly intact
Endocrine: No diaphoresis
Psych: No sign of depression, acute stress, anxiety, ADHD/OCH
UA – positive
hCG – positive 115,000 mlU/ml
Uterine size about 2cm below the umbilicus
A:
12 weeks gestation with nausea
P:
1.
2.
3.
4.
5.
6.
Prescribe prenatal vitamin qd
Supportive care for nausea (phenergan)
Discontinue Ativan, replace with Benadryl 50mg qd at night
Ultrasound and FHT monitoring with Charles Cole Hospital scheduled 9/6/12 at 10am
Offer childbirth classes
Follow-up in 4 weeks or PRN if needed
Education/Guidance
Nutrition & Fitness while pregnant
Communicating pregnancy to children
Gestational diabetes
Candy Hull
Candy Hull, PA-S
9/4/12, 1030am