OBGYN H&P

OB H&P

HPI: Pt is a 25 yo G3P1011 @ 38.9 wks by LMP 5/13/14 c/w 17.0 wk US with EDC 2/17/15. Pt has been receiving PNC from Dr. G. Pt came in last night 7pm with complaints of ctx that was increasing in frequency and intensity. Ctx at admission on 2/3/14 was found to be q4-8 min and cervix was 4/70/hi. Denied VB/VD/LOF. +GFM. Denies CP, SOB, dysuria, N/V, diarrhea, constipation, HA.

Primary OBGYN: Dr. G

Review of Systems

Constitutional:  gravid, No fever, No chills.
Eye:  No blurring, No visual disturbances.
Respiratory:  No shortness of breath, No cough.
Cardiovascular:  No chest pain, No palpitations.
Gastrointestinal:  No nausea, No vomiting, No diarrhea, No constipation.
Genitourinary:  No dysuria.
Neurologic:  Alert and oriented X4, No confusion.

Histories

Past Medical History:
Procedure history: Tonsillectomy as child
Family History: Denies BD/MR/gyn cancers
Social History: Never smoker, no EtOH, no rec drugs
OBHx:

• G1 2005 NSVD FT early cervical dilation
• G2 2013 SAB first trimester
• G3 current

GynHx: Denies abnormal pap, denies STDs.

Physical Exam

VS: BP 125/65, HR 87, RR 15; T 37.3F; 100% O2
General:  Alert and oriented, No acute distress, gravid.
Eye:  Extraocular movements are intact, Vision unchanged.
HENT:  Normocephalic, Normal hearing.
Neck:  Supple, Non-tender.
Respiratory:  Lungs are clear to auscultation, Respirations are non-labored.
Cardiovascular:  Normal rate, Regular rhythm.
Gastrointestinal:  Soft, Non-tender, gravid.
Integumentary:  Warm, Dry.
Neurologic:  Alert, Oriented.
Cognition and Speech:  Oriented, Speech clear and coherent.
Psychiatric:  Cooperative, Appropriate mood & affect.

CE: 4/70/-2 at 12:15pm 2/4/15.
US: V / 1234g (50%) / 4.32 / Fundal placenta
FHT: 120s / mod / reactive, no decels
Toco: Irreg occasional ctx with irritability

Prenatal Labs:

O+/imm/NR
GBS neg
Pap neg
Hep B neg HIV neg
HSV I and II neg
Sickle Cell neg
Quad neg
1 hr GTT 131

A/P: 28 yo G3P1011 @ 38.1 wks by LMP c/w 17.0 wk US with EDC 2/17/15.

Primary Diagnosis: Term contractions
Secondary Diagnosis: IUP @ 38.1 wks, UTI

Term Contractions

– Now irregular, occasional
– No cervical change x2
– Not in labor

UTI

– UA positive
– UCx pending
– CBC pending
– s/p Ampicillin, Rocephin
– Will give Macrobid suppression 100mg PO qday x7 days when discharge

Discussed with Dr. …