Penn Family Medicine Residency

 

Prenatal Visit (Susan Lipson)

Page history last edited by Richard 2 yrs ago

This my prenatal which I call ".prenatal" (imaginitive, huh?!)

 

.name is a .age yo G***P*** at ***w***d here for regular prenatal care.

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

***

Depression screening:

During the past month, have you been bothered by:

a.Little interest or pleasure in doing things? ***

b.What about feeling down, depressed, or hopeless? ***

(Yes to either question is positive screen)

 

OBJECTIVE

prepreg wt  - ***

weight at last visit - ***

current wt - ***

weigt change since last visit - ***

GESTATIONAL PROGRESS:                               

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

 

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

LABS

Urine Culture - ***

If positive for bacteria: Repeated with result of ***

                                      Treated with ***

     TOC on *** with result of ***

Intial labs                   date = ***

   T&S      ***

   CBC     ***

   PAP      ***

   RPR     ***

   RUB      ***

   HBAg    ***

   HIV        ***

Optional labs       date = ***

   GC                 ***

   CT                  ***

   Sickle             ***

   CF                 ***

8-18 wk labs

   *** Quad Screen

   *** Amnio/CVS

24-28 wk labs                     date = ***

   1hr glucola         ***

32-34 wk labs                     date = ***

    hgh/hct                     ***

    U/S                           ***

    GC (if pt is teen)       ***

    CT (if pt is teen)        ***

    GBS                          ***

ULTRASOUNDS

Dating U/S - ***

Anatomy Scan - *** with *** results

Placenta is ***

 

A/P

1. Weight - The patient has gained *** lbs since her

last visit. We discussed the benefits of regular

exercise and healthy dietary choices for herself and

her baby.

2. Medications - the patient is taking her pre-natal

vitamins without difficulty.

3. PTL precautions discussed.

4. F/U  in *** weeks

5. The plan for next visit will be: ***

6. Pts plan for post-partum contraception is ***.

 

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