Tina Sandler – PART 2 –
OBGYN
TINA SANDLER –PART
2-OBGYN TINA
SANDLER –PART 2-
OBGYN
This study source was downloaded by 100000826167209 from CourseHero.com on 06-12-2021 09:42:13 GMT -
05:00
https://www.coursehero.com/file/62247351/OBGYN-Tina-Sandler-
Part2docx/
,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.
co o
eHH ww
10assc/1sh
o. .c
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.
https://www.coursehero.com/file/62247351/OBGYN-Tina-Sandler-
ASSESSMENT/PLAN
Part2docx/
OBGYN
TINA SANDLER –PART
2-OBGYN TINA
SANDLER –PART 2-
OBGYN
This study source was downloaded by 100000826167209 from CourseHero.com on 06-12-2021 09:42:13 GMT -
05:00
https://www.coursehero.com/file/62247351/OBGYN-Tina-Sandler-
Part2docx/
,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.
co o
eHH ww
10assc/1sh
o. .c
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.
https://www.coursehero.com/file/62247351/OBGYN-Tina-Sandler-
ASSESSMENT/PLAN
Part2docx/
