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Betty Richmond Female 27 years (05/02/1987) Alias: Bets
PP: (416) 568-3569
20 min

First time mother prenatal intake

There may be religious concerns regarding care
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  • Signed Encounters
Visit Setting
Visit conducted
in person
in
Select language
via
direct communication
with
Dr. Joseph Feelgood
at
Markham Clinic
on at
Past Medical History
Medications
Problem List
Menstrual History
LMP was 10/03/2014 (date is definite) Periods are regular with normal duration and light flow with no pain.
Male condom was last used on 20/03/201 (used during conception). First period experienced at 12 years of age
Obstetrical History
Gravida: 1
Term: 1
Preterm: 0
Abortions: 0
Living: 1
Date
Sex
Gestational
Age (weeks)
Birth
Weight
Length
of Labour
Place
of Birth
Delivery
Type
Comments
01/03/2012
F
40
3kg
4hrs
MSH
Vaginal
Patient reports history of hypertension
No history of endocrine urinary tract cardiac pulmonary liver hepatitis gastrointestinal gynaecological breast hematological immunological surgery blood transfusion anaesthetic complications psychiatric epilepsy neurological other
No history of congenital heart defect down's syndrome hemophilia muscular dystrophy huntington chorea mental retardation/autism maternal metabolic disorder previous child with birth defects consanguinity cystic fibrosis sickle cell disease or trait other inherited genetic/chromosomal disorder ashkenazi related diseases thalassemia MCV<80 neutal tube defect tay-sachs
No history of varicella susceptible history of STD genital herpes symptomatic bacterial vaginosis syphilis gonorrhea chlamydia tuberculosis risk other
No history of poor social support relationship problems emotional/depression substance abuse family violence parenting concerns religious/cultural issues
No history of diabetes mellitus deep vein thrombosis/pulmonary embolus hypertension (PIH/HT) postpartum depression thyroid abnormalities infertility other
Chief Complaint
Patient comes in for for
Antenatal Visit (9682)
Patient reports nausea, vomiting smoking (3 cigarettes per day, Pt also smokes cigars 1/week) preconceptual folate not initiated before conception
Patient denies bleeding alcohol recreational drugs occupational risks environmental risks dietary restrictions inadequate calcium
Physical Examination
VITALS
Last Recorded on Apr 21, 2014
Graph
Flowsheet
Height:
5 ft 4 in
Weight:
100 lbs
BMI:
17.16
Underweight
BSA:
1.46
Blood Pressure:
145/95 (11:28) sitting
140/90 (11:30) sitting
Examined and normal findings for thyroid chest breasts cardiovascular abdomen varicosities/extrm. external genitalia cervix, vagina uterus (size: ???) adnexae other
Recommendations and Plan
Education and Advice
HIV counselled and declined
Plan Notes
1.
Smoking: Planning to quit cold turkey
2.
Hypertension: Monitor and patient will stay active
3.