Reason for Appointment/Chief Complaint:

1. 32-week OB check

HPI:
30-year-old G2P1 female presents today for a 32-week OB check. She reports she has been
feeling good fetal movement. Has an intermittent pressure in the epigastric region that feels like
the baby is “pushing against her stomach”. Denies any preterm contractions, low back pain or
leakage of fluid. Denies any signs of preeclampsia including spots or blurred vision, right upper
quadrant pain, headaches, or worsening edema. Desires to have the Tdap immunization today.
No other concerns or complaints.

Current Medications:
1. Prenatal vitamin tablet PO once daily

Allergies:
1. NKDA

Past Medical History:

1. None

Surgical History:
1. None

Family History:
1. Mother: Alive, healthy
2. Father: Alive, history of HTN
3. Sister: Alive, history of asthma
4. Brother: Alive, history of asthma

Genetic History:
1. Thalassemia: None
2. Neural Tube Defects: None
3. Congenital Heart Defect: None
4. Down Syndrome: None
5. Tay-Sachs: None
6. Canavan Disease: None
7. Sickle Cell Disease or trait: None
8. Hemophilia: None
9. Muscular Dystrophy: None
10. Cystic Fibrosis: None
11. Intellectual Disability/Autism: None
12. Maternal metabolic disorder: None
13. Huntington Chorea: None

Immunization History:
1. Last Tdap: 2012
 2. HPV: Declined

Infection History:
1. Live with someone with TB or exposed: No
2. History or partner with genital herpes: No
3. Rash or viral illness since last menstrual period: No
4. Previous infection to Varicella: No
5. CMV: No
6. MRSA: No
7. High risk Hep B or Hep C: No

Social History:
1. Tobacco use: None
2. Alcohol use: None
3. Caffeine intake: None
4. Illicit/recreational drug use: None
5. Exercise: Regular physical activity 2-3x/week
6. Occupation: Works full-time
7. Marital status: Married—denies any intimate partner violence
8. Travel outside the U.S: 7/2018, Mexico

Gynecological History:
1. Periods: Pregnant, LMP 11/13/2018
2. Sexual activity: Currently sexually active
3. Date/results of last pap smear: 1/19/2019, pap negative, negative HPV; no history of
abnormal pap smear
4. Last mammogram: None
5. Sexually Transmitted Diseases (STDs): None
6. Birth control: Pregnant
7. Age of Menarche: 11

Obstetric History:
1. Total pregnancies: 2
2. Total living children: 1
3. Miscarriage(s): 0
4. Pregnancy #1: 2015, NSVD, full-term male infant weighing 7 lbs 4 oz
5. Pregnancy #2: Current pregnancy

Review of Systems:
General: Denies fevers, fatigue, rapid weight gain, and recent illness.
HEENT: Denies rhinorrhea, blurred vision.
Respiratory: Denies shortness of breath.
Cardiac: Denies chest pain, palpitations, and edema.
Abdomen: Reports intermittent epigastric pressure associated with baby pushing on
epigastric area. Denies severe/significant/persistent abdominal pain, nausea, vomiting, change
in bowel habits, blood in stool.
GU/Gyne: Denies dysuria, polyuria, vaginal bleeding, change or increase in vaginal discharge.
Neuro: Denies headaches and dizziness.

Objective Findings

Vital Signs:

Temp: Not obtained

HR: Not obtained Weight: 203.8 lbs
RR: Not obtained BMI: N/A
BP: 124/72 mm Hg

Physical Exam:
General: Well developed, well nourished, no acute distress
Psychiatric: A&Ox3, fluent and appropriate speech; maintains good eye contact
Cardiac: Regular rate and rhythm without murmur. No lower extremity edema.
Respiratory: Respirations easy and even. Anterior and posterior breath sounds clear bilaterally.
Abdomen: Bowel sound active. Soft and nontender throughout four quadrants. Fundus
appreciated as documented in OB exam.

OB Exam:
Fundal height: 32 cm
Fetal heart rate: 142 BPM
Fetal movement: Yes
Total weight gain in pregnancy: 28 lbs
Urine: Negative for glucose, nitrates, ketones, blood, and leukocytes
Position: Vertex

Assessment:
1. 32 weeks gestation of pregnancy (Z3A.32)
2. Encounter for immunization (Z23)

Treatment Plan:
1. Administer Tdap immunization
2. Follow up in 2 weeks for next OB visit
3. Counsel on signs of preterm labor, preeclampsia, and normal variations in pregnancy
a. Signs of preterm labor include a tightening pressure that starts from the top of the
abdomen and goes down, leakage of fluid, and menstrual-like cramps
b. Signs of preeclampsia include a headache that is unrelieved by acetaminophen
(Tylenol), visual changes such as stars and spots in vision, and pain in the right
upper abdomen
 c. Round ligament pain is common in the 3rd trimester and can feel like a sharp pain
in the pelvic region cause by sudden movement. It is often relieved with rest,
acetaminophen and heat.

Rationale/Reflection:

The American College of Obstetricians and Gynecologists (ACOG, 2018) state

preeclampsia can occur any time after 20 weeks, although it is most often in the third trimester.
Preeclampsia can lead to significant maternal complications such as an increased risk for heart
attack and stroke (ACOG, 2018). After the first OB visit, we make sure to ask at every
subsequent visit about symptoms of preeclampsia, and emphasize the need to report symptoms
right away.
Youngkin, Davis, Schadewald and Juve (2013) state fetal heart tones (FHTs), fundal
height, blood pressure, and fetal movement should be assessed at each prenatal visit. Urine
should also be evaluated for blood, proteins, glucose and ketones (Youngkin et al., 2013). All of
these elements are the basic components to a prenatal visit. Counseling at prenatal visits is
general but also individualized, including evaluation of complaints or concerns brought by the
patient.

References

American College of Obstetricians and Gynecologists. (2018). Preeclampsia and high blood

pressure during pregnancy. Retrieved from

https:/www.acog.org/Patients/FAQs/Preeclampsia-and-High-Blood-Pressure-During-

Pregnancy?IsMobileSet=false

Youngkin, E. Q., Davis, M. S., Schadewald, D. M., & Juve, C. (2013) Women’s health: A

primary care clinical guide (4th ed.). Upper Saddle River, NJ: Pearson.