NUR MISC-66 OB Cases 1-18

NUR MISC-66 OB Cases 1-18 COMPLEX 2 HOURS EACH CLINICAL CASES: Write TWO SOAP notes on each of these patients 1-INITIAL ENCOUNTER, and 2-FOLLOW UP ENCOUNTER. You do not need to write detailed “S” or “O” in the notes. Chart just the ASESSMENT AND PLAN Leave the NUMBER, NAME, and the CASE DATA at the top of each note. The cases start BELOW: 1/30, Initial Visit—Dxs: 1-maternal FH of DM, 2-Adolescent Pregnancy, 3-smoker. DO NOT REPEAT ALL of the data on Pg 1 (hx and PE). 3/2, 12 wks—vomiting AND 4 lb wt loss requires start on Reglan 10mg QD and QWeekly visits. (Leukorrhea is a normal finding in pregnancy and is not addressed as a problem in a SOAP). 3/29, 16 wks—support hose order, utz yes, due to dx of “post-coital spotting”--but also needs pelvic rest. Order Quad. 4/29, 20 wks—needs diet advice 5/30, 24 wks—Dx of GDM today due to symptoms and RBS of 192 finger stick, and requires referral to Sweet Success program and INSULIN. 6/21, 28 wks—Dx dilutional anemia and required FeSO4 QD order. Also, Antibody Screen. 7/6, 30 wks—Dx of Braxton-Hicks, and recommend rest; Give Rhogam today; +HSV/Rx Zovirax 7/15, 32 wks—Breech presentation is a dx, requires version discussion now and early version is an option—not later. 8/2, 34 wks—GBS order today; or next visit is OK as well. 8/20, 36 wks (at 37wks)--+1 edema/+1 urine protein/Inc Diastolic B/P/Headaches: Dx preeclampsia, and requires a BEDREST order today. Also, tx hemorrhoids today. 8/26, 38 wks—fatigue only—still bedrest 9/9, 39 2/7 wks—Active labor—refer to L&D directly. Good job on postpartum visit and contraceptive visit. Again NO REASON to repeat all of that data when it is already there. Try to treat these visits as real notes--so you get a feel of a real clinical note. If you are going to work toward the next 66 notes--they are simply the Assessment and Plan--so it is less documentation of the hx and PE. #1 & #2) Mary You have been Mary’s provider for the past 3 years. She is a 39-year-old Caucasian woman with a BMI of 32.9 who sees you primarily for her idiopathic chronic hypertension, which is well controlled on an ACE inhibitor. She has smoked 1 pack of cigarettes per day for the past 20 years. She is in today for her annual exam and mentions that she is getting married in a few months and would like to start a family. She has never been pregnant before. Her past medical history is otherwise unremarkable. On physical exam, her vitals are: BP=138/84, Ht=5’ 2”, Wt=180 lbs. Otherwise, her exam is unremarkable. The couple intends to start attempting conception within a few months. Mary Visit# 1 ID: 39 y/o caucasian female CC: Annual physical exam HPI: Patient is a G0P0 here for annual physical exam and conception counseling; patient is getting married and wants to start a family in the next few months. Reports continued smoking and taking her ACE inhibitor daily. Denies any health concerns at this time. A: (1) Encounter for adult physical exam (2) Idiopathic Chronic Hypertension (3) Conception Counseling (4) Obesity (5) Smoking Cessation Counseling P: (1) Collect U/A; Diagnostic lab slip given for CBC, CMP, TSH, Lipid profile, PAPs performed, screening for STD panel (HIV type I & II, HSV-1 and 2 IgG antibody, Hep B Virus Surface Antigen, Hep A IgM antibody, RPR test, urine hCG, Chlamydia/Neisseria gonorrhoeae RNA, TMA), breast exam conducted; SBE taught; (2) Educated about disease process and goal of BP 130/80. DASH diet recommended; Discontinued Lisinopril 10mg PO daily since not recommended during pregnancy and start Nifedipine 30mg daily PO. Educated on importance of good BP control for pregnancy to prevent preeclampsia (3) Recommend prenatal daily vitamin, folic acid 400mg supplement; risks of maternal age and obesity to mother and fetus discussed, advised to avoid OTC medications that are teratogenic, avoid environmental teratogens; screen for Hepatitis B titers, Rubella titers, ; screen for diabetes discussed, (4) Weight loss of 5 -10 lbs recommended to improve maternal health in preparation for conception, HTN and risk for diabetes and cardiac disease. Lab slip for HgA1C; dietary modification advised for healthy heart diet; 40 minutes aerobic exercise 3-5 days/week advised. (5) Educated on common side effects of cigarette use; withdrawal s/s, tx with support groups and addiction counseling. Nicotine patch or gum not recommended when trying to conceive or during pregnancy. RTC in 4 weeks to follow up on blood pressure and lab results. Mary Visit# 2 Date: 3/15/20 ID: 39 y/o caucasian female CC: Rule out pregnancy HPI: Patient is G0P0, and believes she missed her period; reports her regular cycle is every 28 days with moderate flow for 5-7 days; the first day of her last period was 2/24/20. She denies fever, headaches, emesis, nausea, breast tenderness, abdominal pain, vaginal bleeding or discharge. A: (1) Pregnancy at 7 weeks (2) Pre-existing essential hypertension complicating pregnancy (3) Obesity during pregnancy (4) Advanced Maternal Age P: (1) Continue Prenatal Vitamin and 400mg Folic acid daily & recommend Tdap in 3rd trimester; collect UA w/ culture (Urine +), perform PAP, order CBC, Rh antibody screen, STD panel; discussed lab results from previous visit. (2) Pt educated on the importance of controlling BP; maintain a low sodium (DASH) diet; continue Nifedipine 30mg daily. Will continue to monitor if BP 120/80 will discontinue medication (3) Congratulated patient on loss of 10lbs; educated on risks for early pregnancy loss, gestational diabetes, preeclampsia, sleep apnea, carpal tunnel syndrome, macrosomia in infants. recommended appropriate aerobic exercise routine at least 30 minutes 5-7 days a week; Advised to avoid exercise in supine positions and focus on low weights less than 10 lbs, discussed weight gain goal of 11 -20 lbs during whole pregnancy; nutrition class scheduled and discussed low carb intake while increasing protein intake. (4) Discussed increased risk for preeclampsia, placenta previa, GDM, abruption, and possible adverse outcomes for infants w/ increased maternal age; informed about option for screening for aneuploidy and detailed second trimester ultrasound at 18 - 20 weeks. RTC in 4 weeks for routine OB Visit or sooner if any signs of vaginal bleeding or discharge. #3 & #4) Seraphina In urgent care, a 24-year-old woman who has presented complaining of vaginal spotting for the past two days, and which has become heavier today. She says that today’s bleeding is more than a usual period and she became concerned when she passed a large clot. When you enter the cubicle where she is resting, you notice an anxious woman sitting upright. She denies fever, chills, abdominal pain or cramping. She says that she has been urinating more frequently than usual, without pain, and notes fatigue that she attributes to stress at her work as a pastry che