H&P OBGYN

OBGYN-HP-2Download

Nicole Schneider

OBGYN Rotation

Queens Hospital Center

Site Evaluation H&P 2

HISTORY

Identifying Information:

Name: FZ

Sex: Female

Date of Birth: 01/04/1988

Age: 34 years old  

Date & Time: 01/24/22, 9:00AM

Location: Queens Hospital Center

Marital status: Married

Religion: None  

Race: Hispanic  

Source of Information: Self

Reliability: Self  

Mode of Transport: Self  

Chief Complaint: vaginal bleeding x 3 hours ago

HPI:

FZ is a 34 y/o G4P2012 female at 32w2d (d,13) who presents to Labor & Delivery triage for vaginal bleeding that occurred 3 hours ago. The patient noticed a gush of blood from her vagina at 6AM this morning upon getting up from bed, followed by a golf-sized blood clot (seen on photo from phone). She reports the episode occurred only once, and has never occurred before in this pregnancy. The bleeding was not associated with any abdominal, pelvic, or back pain.  She reports good fetal movement. At present, she denies contractions, leaking of fluid, abnormal discharge, abdominal pain, headache, dizziness, fever/chills, nausea, vomiting, dysuria, other urinary or bowel complaints, chest pain, or shortness of breath. She denies taking any anticoagulants/blood thinners.

Antepartum Problem List:

Beta Thalassemia Trait  

  • Husband: sickle cell trait
  • Evaluated by Genetics, with counseling and education 11/8/21
  • Declined amniocentesis and beta-thalassemia DNA analysis

OB History: G4P2012: SAB x 1 (2015 at 5 weeks), FT NSVD x 2 (2017, 2020) both complicated by GDMA1; weights 8-9lbs

Gyn History: Denies uterine fibroids, ovarian cysts, STIs/PID, or abnormal cervical pap smear.

PMH: Beta thalassemia trait

PSH: Denies any previous surgeries or C-sections

Home Medications: Prenatal Vitamin (PNV)

Allergies: No known drug or food allergies. 

Family History: Denies history of gynecologic, breast, or colon malignancies.

Social History: FZ is a 34 y/o female who lives with her husband and 2 children. She denies smoking, excessive alcohol use, or illicit drug use. She is sexually active with her husband only, last sexual intercourse 1 week ago. Denies current use of contraception or barrier protection. Denies recent travel or sick contacts.

ROS:

General: Denies fever, chills, night sweats, fatigue, weakness, loss of appetite, or abnormal changes in weight.

Skin, Hair, Nails: Denies changes in texture, excessive dryness or sweating, discolorations, pigmentations, moles/rashes, pruritus or change in hair distribution. 

Head: Denies headache, dizziness, vertigo, head trauma, unconsciousness, coma or fracture.

Eyes: Denies contacts, glasses, visual disturbances, fatigue, lacrimation, photophobia or pruritus.

Ears: Denies deafness, pain, discharge, tinnitus or use of hearing aids. 

Nose/Sinuses: Denies discharge, epistaxis or obstruction. 

Mouth and Throat: Denies bleeding gums, sore throat, sore tongue, mouth ulcers, voice 

changes, dentures. Last dental exam was 6 months ago.  

Neck: Denies localized swelling/lumps or stiffness/decreased range of motion. 

Breast: Denies lumps, nipple discharge or pain.

Pulmonary System: Denies current dyspnea, SOB, cough, wheezing, hemoptysis, cyanosis, orthopnea or PND, or hx of PE.

Cardiovascular System: Denies chest pain, HTN, palpitations, irregular heartbeat, edema/swelling of ankles or feet, syncope or known heart murmur. 

Gastrointestinal System: Denies change in appetite, intolerance to foods, dysphagia, pyrosis, flatulence, eructation, abdominal/back pain, N/V, diarrhea, jaundice, change in bowel habits, hemorrhoids, constipation, rectal bleeding, blood in stool, stool guaiac/colonoscopy/sigmoidoscopy or pain in flank.

Genitourinary: Denies urinary frequency, change in color of urine, incontinence, hematuria, dysuria, nocturia, urgency, oliguria or polyuria.

Sexual History: Patient is sexually active with husband only. Denies anorgasmia, known sexually transmitted infections or the use of contraception/protection. 

Menstrual: Denies dysmenorrhea, menorrhagia, metrorrhagia, PMS, postcoital bleeding, vaginal discharge, dyspareunia or menopause. Last cervical pap 2020- normal.

Obstetrical: G4P2012, SAB x 1, FT NSVD x 2. Admits to one episode of vaginal bleeding x 3 hours ago. Denies contractions or leakage of fluid.

Musculoskeletal System: Denies joint or muscle pain. Denies redness, deformity or swelling.

Peripheral Vascular System: Denies intermittent claudication coldness or trophic changes, varicose veins, peripheral edema or color change. 

Hematologic System:Denies anemia, easy bruising or bleeding, history of DVT/PE, or lymph node enlargement.

Endocrine System: Denies polydipsia, polyphagia, polyuria heat or cold intolerance, goiter or hirsutism. 

Nervous System: Denies seizures, loss of consciousness, sensory disturbances (numbness, paresthesia, dysesthesias, hyperesthesia), ataxia, loss of strength, change in cognition/mental status/memory or weakness.

Psychiatric: Denies depression/sadness (feelings of helplessness, feelings of hopelessness, lack of interest in usual activities, suicidal ideation), anxiety, obsessive/compulsive disorder, or ever seeing a mental health professional. 

Prenatal Course:

  • LMP: 06/04/2021
  • First prenatal visit: 09/03/21
  • Last prenatal visit: 12/17/21
  • Total # of visits: 4
  • Total # of prenatal hospitalizations: 0

PHYSICAL EXAM:

Vital signs:

BP 116/80

P 88 (regular)

RR 18 (unlabored)

Temp 98.1 F (oral)

spO2 99% (RA)

BMI 39.30

General: 34 y/o female, A&Ox3. Patient is well-appearing, in no apparent distress/pain.

Skin: Skin is warm, good turgor, nonicteric, no lesions or masses.

Heart: Regular rate and rhythm. S1 and S2 present, with no murmurs, gallops, S3, S4, or friction rubs.

Lungs: Clear breath sounds in all lung fields. No adventitious sounds. Breathing is unlabored with no accessory muscle use.

Abdomen:. Bowel sounds normoactive in all 4 quadrants. Abdomen tympanic throughout, with no tenderness to palpation, no guarding noted. No CVA or rebound tenderness. Gravid uterus noted.

Sterile Speculum Exam: Minimal bleeding noted in vaginal canal, no frank pooling, cervical os closed, membrane intact.

Extremities: No bruising, bleeding, erythema, swelling or edema noted. Lower extremities symmetrical and nontender bilaterally.

Baby FHR:

  • FHR – present
  • Baseline rate – 130 bpm
  • Baseline classification – normal
  • Variability – Moderate
  • Pattern – accelerations only
  • Category 1

Uterine Activity

  • Uterine contractions: absent

OB Ultrasound

  • Vertex presentation
  • Posterior previa placenta
  • AFI 15 cm
  • +fetal movements

RESULTS:

Prenatal Labs:

Blood Type: B+

HbsAg: neg

HIV: neg

Rubella: immune

Rubeola: immune

GCT: within normal limits

Syphilis Screen: neg

GC/CT NAAT: neg

Quantiferon: neg

Hemoglobin Electrophoresis: beta-thalassemia trait

Lead: <1

CF: neg

Spinal Muscular Atrophy: neg

Fragile X: neg

Pap: Negative for intraepithelial lesion or malignancy

3rd Trimester:

GBS: pending

HIV: pending

Syphilis: neg

PLAN:

Assessment:

34 year old G4P2012 at 32w2d (d,13) with 1 episode of unprovoked 3rd trimester vaginal bleeding, found to have posterior placenta previa on sonogram. Patient being admitted to L&D for observation. 

BP: normotensive

UA: pending

FHT: 130 baseline, moderate variability, accelerations, Category 1.

Toco: contractions absent

Sono: vertex, posterior placenta previa, AFI 15

EFW: 2,400gm (bedside sono)

SSE: minimal bleeding, cervical os closed, membrane intact.

Plan:

  • Consent and admit to L&D: observation for placenta previa with 1 episode of bleeding
  • Clear liquid diet
  • IV fluids: LR
  • CBC, T&S, coags, syphilis
  • f/u 3rd trimester HIV lab
  • GBS swab
  • 2 units pRBC’s on hold
  • Monitor toco / electronic fetal monitoring / vital signs
  • DVT prophylaxis: sequential compression devices
  • Pain management PRN: Tylenol