Tina Sandler - Part 2 OBGYN/OBGYN Tina Sandler Part 2: Latest-2021, a complete document for exam

Tina Sandler – PART 2 –
OBGYN

TINA SANDLER –PART
2-OBGYN TINA
SANDLER –PART 2-
OBGYN




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,Tina Sandler – PART 2


Physical
Exam:




Tina Sandler – PART 2 – OBGYN

Diagnosis – Prenatal checkup (Pregnancy) – Domestic Violence
Test Results:
Prenat  checkup 24w,
Obstetric fall (DV), headache,
ultrasound: Structural constipation, hx preeclampsia,
survey of pregnancy hx ectopic
yields normal results.preg, hx intrauterine
fetal  demise,
OGTTPE(Oral
– bruise LLQ tolerance
glucose abd, PE – bruise l breast– no indication of gestational diabetes
test): Normal
Tests- obsUrinalysis: UA TSH
normal
us, UA, CBC,
 CBC, PT/INR, PTT/aPTT: Normal (ordered due to bruising)
Problem Statement:
TSH / FT4: Normal
( Management
Demographic Plan
description – chief complaint – Hx and PE key findings – risk factors )

Continue prenatal vitamins.

 Supportive care for Headaches – notify clinic if increased problems.
Tina Sandler is a G5P1 woman presenting at 24weeks gestation for prenatal checkup. She reports falling
 Counsel for manner of delivery
in a domestic altercation with her intoxicated husband. On physical exam she has a large bruise in her
 Psychological analysis with referral to social services.
abdomen LLQ, hyperechoic sounds are heard in her abdominal RUQ, fetal heart rate is 140, there is also
 Discharge patient only when sure she is in a safe environment.
a 5x5in bruise on her left breast. She reports new headaches and ankle edema on standing. Patient hasa




mm
 Obtain sexual history to evaluate if she is being coerced for sexual activity
erero asas
history of ectopic pregnancy and preeclampsia and 3rd trimester loss of pregnancy.



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10assc/1sh
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rsrse e e

CC: Tina Sandler is a 29 year old G5P1 woman presenting at 24 weeks gestation for prenatal checkup -
ouou urucrc


She reports falling in a domestic altercation with her intoxicated husband.

HPI: Patient reports in a fight with her husband she ‘fell down the stairs’ - On physical exam she has a
a C C s so




large bruise in her abdomen LLQ, hyperechoic sounds are heard in her abdominal RUQ, fetal heart rate is
140, there is also a 5x5in bruise on her left breast. She reports new headaches and ankle edema on
o
vi ia rere




standing. She describes her headaches as new and starting in the mornings.

Meds: Prenatal vitamins
ed d d dy




PMH: Patient has a history of ectopic pregnancy and preeclampsia and 3rd trimester loss of pregnancy.
y
arare stutu




SH: Patient reports that she is not currently smoking cigarettes, drinking alcohol, or using recreational
drugs while pregnant
shsh is is s
v




ROS: Only positive findings are seen in HPI
ThTh




VS: Pulse – 78; BP – 118/78 RR – 14; T – 98.6F (37 C); SpO2 – 94%

Abdomen: A large bruise (4 – 6cm) is seen in LLQ – fetal movement is palpated, fetal heart rate 140bpm.
Hyperechoic sounds are heard on auscultation of RUQ of abdomen.

Chest: This
A large
study bruise is downloaded
source was seen on the Left breast from CourseHero.com on 06-12-2021 09:42:13 GMT -
by 100000826167209
05:00
Gynecologic: Speculum exam shows no bleeding.
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