.name is a .age yo G***P*** at ***w***d here for initial OB visit.

LMP is *** which gived EDD of ***

U/S on *** which gave GA of ***w***d which gives EDD of ***

FINAL EDD ***

Issues for this visit -

*** FM

*** CTX

*** VB

*** LOF.

*** N/V

*** HA

*** edema

*** other concerns

ISSUES FOR THIS PREGNANCY

***

.allergy

 .OB

----------------------

Menstrual History

LMP definite? {:64}

Periods are {reg/irreg:715}, lasting {number:10} days.

prior menses (date): ***

Birth control at time of conception: {contraception:706}

Menarche (age of onset): *** yrs

Endocrine/Infertility Hx?: {:60}

STD Hx:{STD history:60}

History of abnormal Pap smear: {abnl Pap:60}  Last Pap: ***

History of abnormal mammogram: {abnl mammogram:60} BSE: ***  

----------------------

     Past Pregnancies:

    date     GA  outcome weight sex name   complications

  ***/***/*** ***w   ***   ***kg  ***  ***   ***

  ***/***/*** ***w   ***   ***kg  ***  ***   ***

  ***/***/*** ***w   ***   ***kg  ***  ***   ***

----------------------

    Past Medical History

1.  Diabetes             {:60}     

2.  HTN                  {:60}     

3.  Hrt Disease          {:60}     

4.  Autoimm. Dis         {:60}     

5.  Kidney Dis./UTI      {:60}     

6.  Neuro/Epilepsy       {:60}          

7.  Psychiatric          {:60}        

8.  Hepat/liver ds       {:60}     

9.  Varicos./Phleb.      {:60}  

10. Thyroid disfnct      {:60}     

11. trauma/Dom.Viol.     {:60}     

12. Hist. of bld transf. {:60}     

                   amt/day        amt/day       #years

                   prepreg       pregnancy      of use

13. Tobacco          ***           ***           ***

14. Alcohol          ***           ***           ***

15. Street drugs     ***           ***            ***

16. D (Rh) sensitized    {:60}

17. Pulmonary(TB, Asthma){:60}

18. Allergies (drugs)    (see below)

19. Breast               {:60}

20. GYN surgery

    --***

    --***

21. Operations/hosp'ns (yr/reason)

    .psh

22. Anesthetic comp'ns  {:60}

23. History Abnl PAP    {:60}

24. Uterine anomaly/DES {:60}

25. Infertility         {:60}

26. relevant FH         (see below)

27. Other:              SSD or trait?: {:60}

                        MVI/Folic acid:: {:60}

                        ***

-----

.med

------------------------------------------------------

       FHx:

Mother: {live/deceased:100267}

Father:  {live/deceased:100267}

Breast Ca: {relationship:20}    OV Ca: {relationship:20}   Uterine Ca: {relationship:20}  Colon Ca:  {relationship:20}

Heart Disease:  {relationship:20}     Osteoporosis:  {relationship:20}     DM {:60}     HTN {:60}

other med. conditions: ***

------------------------------

     Genetic Screening/Teratology Counseling

Patient's age is >= 35 years?  {:63}

Thalassemia (Italian, greek, Mediterranean, Or Asian Backround):

MCV < 80? {:63}

Neural Tube defect (Mennogomyelocele, Spina Bifida, or Anencephaly?  {:63}

Congential Heart Defect?  {:63}

Down Syndrome?  {:63}

Tay-Sachs (EG: Jewish, Cajun, French Canadian)?  {:63}

Sickle cell Disease or Trait(African)?  {:63}

Hemophilia?  {:63}

Muscular Dystrophy? {:63}

Cystic Fibrosis? {:63}

Huntington Chorea?  {:63}

Mental Retardation / Autism? {:63}

     If Yes, Was Person tested for fragile X? {:63}

Other Inherited Genetic or Chromosomal Disorder? {:63}

Maternal Metabolic Disorder(EG:Insulin Dependent Diabetes, PKU)? {:63}

Patient or Baby's Father had a child with birth defects not listed above?  {:63}

Recurrent Pregnancy Loss, or a stillbirth?  {:63}

Medications / Street Drugs / Alcohol Since last menstrual Period?  {:63}  If yes, Agent(s): ***

Any Other? {:63} ***

----------------------

Infection History

1. High risk Hepatitis B/Immunized {:60}

2. Live with someone with TB or exposed to TB {:60} 

3. Patient or partner has history of genital herpes {:60}

4. Rash or viral illness since last menstrual period {:60}

5. History of STD, GC, Chlamydia, HPV, Syphilis {:60}

    h/of    Rubella: {:64}    Varicella: {:64}

6. Other ***

----------------------

ROS:

General Health: appearance: {appearance:50},  fatigue: ***

        diet: ***

Gastrointestinal: {GI:600}

Genitourinary: {GU:700}

Breasts: {breast:1202}

Skin: {skin:101}

Cardiovascular: {CV:500}

Pulm: {Resp:400}

Neuro: {Neur:900}

Heme: {Hem:1100}

Musculoskeletal: {musculoskeletal:803}

Eyes: {Eyes:200}

Psychiatric: {Psych:1000}

Endocrine: {Endo:1200}

----------------------

Physical Exam:

.VS

Ave prepregnancy wt: ***,    Wt change: ***,  Ht: ***

General appearance: {appearance:50}

Skin: {:101}

HEENT: Head: {:301}, Eyes: {eyes:201},  Ears: {ears:322}, Nose/Sinuses: {nose:302}, Oropharynx: {O/P:303},  Neck: {neck:304}

Breasts: {breast:1202}

Respiratory: {lungs:401}

Cardiovascular: {heart:501}

Abdomen: {abdomen:601}

Back: {back:801}

Extremities: {extremities:802}

Musculoskeletal: {musculoskeletal:803}

Neuro: {neuro:901}

Pelvic:

(This portion of exam performed with assistance of MA: ***).

External Genitalia:{RWH EXTERNAL GENITALIA:100320} 

Vagina: {RWH VAGINA:100321}

Pelvic Supports: {RWH PELVIC SUPPORTS:100322}

Diagonal Conjugate: reached {:60}; cm: {:6}

Spines: average {:63}, prominent {:63}, blunt {:63}

sacrum: concave {:63}, straight {:63}; anterior {:63}

subpubic arch: normal {:63}, wide {:63}, narrow {:63}

gynecoid pelvic type {:63}

Cervix: {RWH CERVIX:100324}

Uterus: {RWH UTERUS:100325}

Adnexa: {RWH ADNEXA:100326}

Anus and Perineum:  {RWH ANUS AND PERINEUM:100327}

Rectum:  {RWH RECTUM:100328}

Hemoccult: {Hemocult:100280}

GESTATIONAL PROGRESS:                               

Day:  GA:  fnht:  fhr:  pres:  fm:  ptl:  cvx:  edema:  BP:  Wt:   gl/pr/le

A/P:

.diag

 

 

.timestamp