Nursing - Gyn Soap Note

GYN SOAP NOTE History of Present illness: P.B. is a 27-year-old G1P0 African American pregnant female at 36 weeks and 0 days, who presents to Sunriver Health for routine third trimester prenatal visit. Last menstrual cycle was on 6/29/2021. Patient reports her previous cycles are normal, occurring every 28-30 days with 5-7 days of bleeding, moderate bleeding days 1-3, and light bleeding to spotting days 4-7. Patient has no recent medical issues outside of pregnancy. Patient states she has experiences lower back and lower abdominal pain. Patient reports the pain is mild, irregular contractions/ cramps, that last for about one hour. Patient rates the pain a 4 out of 10 on a 0 to 10 pain scale. The pain is felt usually after a long day at work. Pain is usually relieved with rest or warm shower. Patient denies taking any over the counter analgesics for pain relief. Patient denies cramping has an effect on day-to-day activities. Patient reports positive fetal movement, denies leaking of fluid, no vaginal bleeding, headaches, dizziness, blurry vision, right upper quadrant pain. Denies any nausea and vomiting. Patient desires a vaginal delivery. Patient currently taking one prenatal vitamin orally daily. PMH: none PSH: Left Knee ACL repair 2015 Allergies: NKDA Untoward Medication Reactions: none Immunization Status: Flu vaccine 11/2021 Covid Vaccine Pfizer 10/9/2021 (first dose) 10/30/2021 (second dose) no booster TdaP given 2/2022 MMR 8/15/2021 positive (titer) Varicella 8/15/2021 positive (titer) HepB Surface AB 8/15/2021 reactive (titer) TB QuantiFERON 10/16/2021 negative Dating Criteria: 1. LMP 6/29/2021 2. First Sonogram- dating 9/21/2021 at 12 weeks 3. Level II sonogram- anatomy11/16/2021 at 20 weeks OB History: 1. Current- Primipara Females: age of menarche 11 Regular menstrual cycles Last pap smear: 2/3/ 2020- NILM (negative) Screenings: GBS screening FMH: children- none sister- A/W 24yo brother- A/W 32yo mother- A/W 49yo father- A/W 50yo grandmother (maternal) A/W 67yo grandfather (maternal) A/W 75yo grandmother (paternal) living 69yo, hypertension diagnosed age 56 grandfather (paternal) A/W 70 Personal History/Social History: Patient is married, male partner. Lives with husband in an apartment in Brooklyn, NY. Patient does not exercise regularly; reports she does not have the time. Employed as a medical assistant and going to school part time to become a nurse. Enjoys knitting and cooking. Denies drinking alcohol during pregnancy, nonsmoker, smoke free home. Denies abuse, neglect, depression, anxiety. Denies any illicit drug use. Sexual History: 1 male partner, unprotected sex, no condom use Current Medications/OTCs/Supplements: indicate Dose, Route, Frequency Prenatal vitamin- 1 tablet, oral, daily Review of Systems: General: denies any headaches, fever, recent illness. Skin: denies any lesions, rashes, itchiness. Reports stretch marks on abdomen. Neck: denies difficulty swallowing, pain or swelling. Chest: denies difficulty breathing or chest tightening. Cardiovascular: denies any palpitations. Breasts: denies any pain, palpable masses, reports small amount of clear/white discharge from nipple when compressed. Gastrointestinal: reports mild lower abdominal cramping. Relieved by rest or hot shower. Genitourinary: denies any urgency, incontinence, changes in color/ odor, dishcarge, hemturia, dyspaurenia. Musculoskeletal: reports mild aching lower back pain. Relieved by rest or hot shower. Psychiatric: denies any mood swings, mood disorders, depression. Screening Tool: PHQ-2 Depression Scale (Patient Health Questionnaire-2) Over the last 2 weeks, how often have you been bothered by the following problems? 1. Little interest or pleasure in doing things- 0 not at all 2. Feeling down, depressed or hopeless- 0 not at all Score: negative 0 points Physical Exam: Vital Signs: Blood Pressure- 11076 P- 63 RR-18 T- 36.6 degrees Celsius Height- 5 ft 7 in Weight- 175lbs BMI- 27.41 and pre-pregnancy weight 155lbs. 20lb weight gain, appropriate for patients weight and fetus gestational age. General: Well-nourished and dressed appropriately. Appears welcoming and happy. Skin: warm, dry, intact, no lesions, no scars, no open wounds. Neck: neck exam deferred. Chest: respiratory exam deferred. Cardiovascular: cardiovascular exam deferred. Breasts: medium sized, symmetrical in shape and size, pendulous, symmetrical nipples. No discharge, no lesions, no tenderness, no masses. Abdomen: Gravid, soft, no lesions, no scars, no open wounds. No areas of tenderness. FHR- 140s-150s. Vertex presentation. Genitourinary: No discharge, nontender. GYN/Pelvic: Fundus is midline, firm, and nontender. Fundal height measuring 35cm, fetal growth appropriate for age. External genitalia-fine, short, minimal hair evenly distribute. No lesions, rashes, open wounds noted to vulva and labia. No body piercings noted. No masses or inflammation noted to Bartholin glands. Clitoris and clitoral hood nontender. Vagina is pink, moist, no excessive or odorous discharge, no bleeding. Cervix is closed to palpation. Rectal: no rectal exam performed Neurological: Patient is pleasant. Alert and oriented to person, place, and time. Answers questions appropriately. Peripheral Vascular: no edema, capillary refill less than 3 seconds Pertinent Labs/Diagnostic Testing: Current visit: Urinalysis for glucose, protein, ketones, bacteria, and blood. Negative protein, negative glucose, negative bacteria, trace Ketones. Group B strep screening. Previous Visits: GCT- 88 Quadruple screen- normal AFP- normal TSH- normal Varicella- positive CBC- normal with mild anemia hgb 10.3, hct 31.2 Hep B Surface Antigen- NR HIV- NR RPR- NR MMR- Immune ABO- O+, antibody Negative Chlamydia- Negative Gonorrhea- Negative Differential Diagnosis Diagnostic Reasoning Exercise: Lower Back and Abdominal Pain Differential Diagnoses Pathophysiology Pertinent Positives 1. Braxton Hicks Spontaneous tightening of uterine muscle anywhere from 30-60 seconds. Low Back pain Abdominal pain No real pattern Abdominal tightening Pertinent Negatives 2.Preterm Labor 3. Urinary Tract infection Contractions with uterine cervical length change before 37 weeks. goes away with position change Do not increase in frequency or strength Abdominal pain Low Back Pain Abdominal pain Low back pain change in cervical length painful tightening on top of fundus regular pattern increase in frequency and strength leakage of fluid Urinalysis Negative for bacteria Dysuria Cloudy dark urine Foul smelling urine Strong persistent urge to urinate Fever Burning with urination Narrative: P.B. is a 27-year-old G1P0 African American pregnant female at 36 weeks and 0 days, who presents to Sunriver Health for routine third trimester prenatal visit. Prenatal history unremarkable, patient is fully vaccinated. P.B. is due for GBS screening today. P.B. reports lower back and abdominal pain/ cramping in the third trimester. The pain feels like abdominal tightening that come and go, no pattern, no increase in frequency and strength. Rates pain a 4 out of 10 on a 0-10 pain scale. Patient reports they usually occur after a long day at work or school. Patient reports pain usually goes away after rest or warm shower. Assessment/Plan: Suspected Braxton Hicks contraction, rule out Preterm Labor and UTI. Braxton Hicks contractions occur sporadically and do not increase in strength. They are irregular in duration, frequency, and intensity, are unpredictable and non-rhythmic and are more uncomfortable than painful (McEvoy, 2021) Pertinent patient positives: lower back and abdominal pain, irregular, no increase in frequency or intensity, no cervical change. Preterm labor pertinent patient negatives: patient denies any leakage of fluid or bleeding, increase frequency or strength of the tightening, on exam cervix was closed and not effaced. As stated by Huang et al., Preterm labor (PTL) occurs between 20 0/7 to 36 6/7 weeks of pregnancy and presents as regular uterine contractions occurring with resultant cervical change(s) (dilation, effacement, or both) or initial presentation of regular contractions and cervical dilation of at least 2 cm (2022). UTI is one of the most common bacterial infections in pregnancy (Kruthipati et al., 2021). Pertinent patient negatives: patient denied bladder pain, dysuria, cloudy dark urine, foul smelling urine, fever, or burning with urination. Urinalysis negative for blood or bacteria. UTI is diagnosed by clinical findings of bacteriuria (bacteria in midstream urine in counts of >105 colony forming units (cfu)/mL) along with symptoms reported by the patient (Kruthipati et al., 2021). Order GBS rectal swab and collect specimen. Promote healthy iron and fiber fortified diet, consume vegetable and protein. Encourage regular physical activity for healthy pregnancy and lifestyle. Promote adequate rest. Encourage increase in oral hydration due to trace ketones in urine reflecting dehydration. Third trimester education: kick counts, preterm labor, appropriate weight gain. Education on when to call the office: fever, bleeding, decrease fetal movements, contractions lasting one minute, every 5 minutes, lasting longer than one hour, unrelieved by position changes. Education to avoid cat litter due to toxoplasmosis. No referrals or services at this time. Return to office in one week for OB visit or as needed. Plan should be referenced using UpToDate/Access Medicine as the resource 1. Diagnosis # 1 ICD-10 ENCOUNTER FOR SUPRVISION OF NORMAL FIRST PREGNANCY, THIRD TRIMESTER a. Orders placed for urinalysis b. Obtain and analyze urine specimen for bacteria, blood, glucose, ketones. c. Blood pressure check to assess for preeclampsia d. Leopold’s maneuvers to assess fetus position e. Assess fetal heart tones f. Measure fundal growth for fetal growth g. Encourage increase of oral hydration h. Discuss appropriate weight gain in the third trimester, 0.5-1lb per week i. Discuss and encourage physical activity for healthy pregnancy and lifestyle j. Discuss signs of true labor k. Discuss kick counts- 10 fetal movements in 1 hour reflects positive fetal health. If less contact provider. 2. Diagnosis # 2 ICD-10 Z3A.36 - 36 WEEKS GESTATION OF PREGNANCY a. Orders placed for group B strep screening b. Obtain vaginal cultures c. Discuss signs of preterm labor Health Maintenance: Nutritional and exercise counseling Depression Intimate Partner Violence Lipid Profile Sexual Assault Tobacco, Alcohol, and other Drug Use Reproductive Sexual Health Family Planning and Contraception counseling STD and HIV screening and counseling Wellness and health maintenance and coaching Covid vaccine education RTC: Return weekly for routine third trimester OB visit or as needed. Decrease fetal movement, leakage of fluid, or bleeding, persistent headaches or vision changes notify provider and go to hospital. Group B strep results will be uploaded to patient portal. MD will call patient with final result. If positive patient will require antibiotics; Penicillin, in labor. FACULTY ONLY Grade __________