Focused Exam: Non-Reassuring Fetal
Status- Transcript
,I. FULL CASE STUDY
A. PATIENT DEMOGRAPHICS
Demographic Detail
Name Luna Morales
Age 35 years old
Sex Female
Race/Ethnicity Puerto Rican
Gestational Age 40 weeks, 2 days
Gravida/Para (Not fully specified in available records)
Setting Labor and Delivery Unit
Reason for Encounter Admitted for labor induction
Admitting Provider Dr. Jodi Newman
B. HISTORY OF PRESENT ILLNESS (HPI) — OLDCARTS Format
Component Findings
Onset Symptoms began with onset of labor approximately 7 hours ag
Location Upper abdomen
,Component Findings
Duration 7 hours, ongoing
Character Dull pain in upper abdomen associated with contractions
Aggravating
Uterine contractions
Factors
Relieving Factors Repositioning, breathing techniques
Radiation None
Timing Contractions occurring every 5 minutes, lasting 1 minute
Severity Pain 5/10 on pain scale
Associated Non-reassuring fetal heart rate pattern (variable decelerations
Symptoms water breaking during OB appointment
Chief Complaint (CC):
"I'm here for my labor induction. My water broke during the
appointment."
History from Patient:
Luna Morales is a 35-year-old Puerto Rican female, G1P0 (or similar), at
40 weeks and 2 days gestation, admitted for labor induction. She
presented to her OB office for a scheduled appointment to discuss
induction when her water broke spontaneously during the visit. She has
been in labor for approximately 7 hours. Her uterine contractions occur
every five minutes and last approximately one minute, causing a dull pain
in her upper abdomen rated 5/10. The fetal heart rate monitor currently
indicates variable decelerations, suggesting possible umbilical cord
compression. She reports that her amniotic fluid is clear and odorless.
, C. PAST MEDICAL HISTORY (PMH)
Condition Details
No Major Medical
Denies high blood pressure, diabetes
Conditions
Headaches Reports headaches coinciding with blurry vision
Reports chest tightness during asthma exacerbations,
Asthma
denies current chest tightness
Past Surgical History (PSH):
• (Not specified)
Allergies:
• (Not specified)
Medications:
• (Not specified)
Immunizations:
• (Not specified)
D. FAMILY HISTORY
Status- Transcript
,I. FULL CASE STUDY
A. PATIENT DEMOGRAPHICS
Demographic Detail
Name Luna Morales
Age 35 years old
Sex Female
Race/Ethnicity Puerto Rican
Gestational Age 40 weeks, 2 days
Gravida/Para (Not fully specified in available records)
Setting Labor and Delivery Unit
Reason for Encounter Admitted for labor induction
Admitting Provider Dr. Jodi Newman
B. HISTORY OF PRESENT ILLNESS (HPI) — OLDCARTS Format
Component Findings
Onset Symptoms began with onset of labor approximately 7 hours ag
Location Upper abdomen
,Component Findings
Duration 7 hours, ongoing
Character Dull pain in upper abdomen associated with contractions
Aggravating
Uterine contractions
Factors
Relieving Factors Repositioning, breathing techniques
Radiation None
Timing Contractions occurring every 5 minutes, lasting 1 minute
Severity Pain 5/10 on pain scale
Associated Non-reassuring fetal heart rate pattern (variable decelerations
Symptoms water breaking during OB appointment
Chief Complaint (CC):
"I'm here for my labor induction. My water broke during the
appointment."
History from Patient:
Luna Morales is a 35-year-old Puerto Rican female, G1P0 (or similar), at
40 weeks and 2 days gestation, admitted for labor induction. She
presented to her OB office for a scheduled appointment to discuss
induction when her water broke spontaneously during the visit. She has
been in labor for approximately 7 hours. Her uterine contractions occur
every five minutes and last approximately one minute, causing a dull pain
in her upper abdomen rated 5/10. The fetal heart rate monitor currently
indicates variable decelerations, suggesting possible umbilical cord
compression. She reports that her amniotic fluid is clear and odorless.
, C. PAST MEDICAL HISTORY (PMH)
Condition Details
No Major Medical
Denies high blood pressure, diabetes
Conditions
Headaches Reports headaches coinciding with blurry vision
Reports chest tightness during asthma exacerbations,
Asthma
denies current chest tightness
Past Surgical History (PSH):
• (Not specified)
Allergies:
• (Not specified)
Medications:
• (Not specified)
Immunizations:
• (Not specified)
D. FAMILY HISTORY
