History and Physical

In: Other Topics

Submitted By pameladeb
Words 845
Pages 4
I. Identifying information
A.Gender: Female
B.Age: 36 years old
C.Place of Interview: New York Downtown Hospital
D.Source of information: patient, patients chart
E.Statement of reliability: Patient was coherent and reliable

II. Chief Concern Patient was admitted to the labor and delivery department because of vaginal bleeding and lower abdominal pain.

III. History of Present Illness The Patient is a 36 year old female, G2P1001, that is 28 3/7 weeks pregnant who presented to the emergency room with bloody mucus discharge, active vaginal bleeding, abdominal pain and occasional lower back cramps. A McDonald cerclage was placed on 10/13 due to thinned cervix and fear of miscarriage. Upon speculum examination, her cervix was closed and the cerclage was correctly in place. She was given two doses of betamethasone (12/3,12/4). She denies headache, dizziness and vision problems. She had a normal vaginal delivery in 1998 with no complications.

IV. Past Medical History Medications: 1.Prenatal vitamins- 1tab/day, PO Past Medical Diagnoses: Patient denies any previous medical conditions. She stated that is has always been in good health and no previous diagnoses.

Allergies: No known allergies Immunizations/vaccines: All of the patient’s immunizations were “up to date” Blood Transfusions/Surgical History: No transfusions, only surgery was the current cerclage placement and an appendectomy in 1982.

V. Social History The patient denies ever smoking. She does not drink alcohol and has never done any illicit drugs.

VI. Family History: No known family history of cancers. No reliant family history, no complicated births or gynecological problems. No family history of hypertension or diabetes.

VII. Review of Systems General: The patient has been gaining weight appropriately to what is expected in the pregnancy.…...

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