OB WORKUP NORMAL

INITIAL ASSESSMENT OF LEARNING CHALLENGES OF PATIENT/FAMILY: No

barriers identified.
LEARNING PREFERENCES: Both written and verbal explanations.
Is a *-year-old * female. G*T*P*A*L*. Last menstrual period was * and was*. This
gives her an EDC of * which makes her * weeks preganant. She presents today to
maternity counseling for an OB workup. She has had a positive pregnancy test at
home which is confirmed today at our lab. Patient states pregnancy was *. Patient is
* about this pregnancy. Significant other is *.
REVIEW OF SYSTEMS: Current symptoms include *. Denies history of blood
transfusions, infectious diseases, blood dyscrasias, or thromboembolic disease.
Denies history of gastrointestinal, liver, kidney, or cardiac disease. No history of
reaction to anesthetic agents. She * wear contact lenses.
For current pregnancy, see CPN. Denies history of hemorrhoids, varicosities, or leg
cramps. No exposure to x-rays or infections. No risk factors or toxoplasmosis
exposure.
PREVIOUS PREGNANCY HISTORY: *
OBSTETRIC/GYNECOLOGIC HISTORY:
Periods are *. Last Pap smear was *. Contraception history is *.
Denies problems with dysmenorrhea, dysfunctional bleeding, sever
nausea/cramping or PMS associated problems with menses. Denies history of
abnormal Pap smears, cervical disease or surgery, DES exposure, breast cancer,
sexually transmitted diseases, toxic shock syndrome, pelvic inflammatory disease,
or problems with infertility.
PAST MEDICAL HISTORY: Significant for *. The patient * chicken pox. Last TB skin
test was * and was *.
PAST SURGICAL HISTORY: Significant for *.
IMMUNIZATIONS: See EMR for more details. Last tetanus was *.
ALLERGIES: *.
CURRENT MEDICATIONS: Medication list is updated in EMR.
FAMILY HISTORY: Significant for *.
RELIGION: *.
VITAL SIGNS: Pre-pregnancy weight *. Todays weight *. Height *.
PATIENT PROFILE: * is * and lives with * who * supportive of the pregnancy. She is
*. She * tolerating her job. She * tolerating her pregnancy well. * is employed at * as
a *. Education level completed by patient *, significant other *. The patients
caffeine intake is *. Exercise/heavy labor consists of *. Smoking *. First * for abuse,
rape, or sexually transmitted diseases. Street drugs *. Alcohol *. Seat belt use *.
LABORATORY: The patients initial prenatal lab work was ordered which includes a
CBC, prenatal profile, HIV, TSH, hepatitis B, and urine.
PREGNANCY RISK FACTORS: Significant for she * on a special diet at this time.
MATERNITY COUNSELING OBSTETRICAL WORKUP TEACHING: Per protocol.
CURRENT KNOWLEDGE ASSESSMENT: Understands objective/has necessary
skills for self-management.
READINESS TO LEARN/BARRIERS TO LEARNING: Accepting.
TEACHING METHODS: Verbal discussion and printed material.
OUTCOMES AND REINFORCEMENTS: Patient verbalizes understanding.
Patient will return for her next doctor appointment with * on *. With the assistance
of the clinical staff the patient will be scheduled for 28 and 36 week Maternity
Counseling sessions.