H&P 1
OB-GYN

 

Identifying Information:

Name: KR

Age: 20

Sex: female

Race: Hispanic

Date and Time: 06/12/2021 17:00

Location: Woodhull Medical Center – Labor and Delivery Triage

Source of Information: self

Mode of Transport: taxi

 

Chief Complaint: headache x 6 hours

 

History of Present Illness:

KR is 20 yo G2P1001 female at 31w5d gestation by LMP with PMH significant for pre-eclampsia in prior pregnancy with induction of labor at term presenting with headache for 6 hours that was initially accompanied by dizziness and nausea without emesis. Patient stated that headache started in the morning after she finished eating breakfast, with pain to the front and sides of head described as 10/10 dullness. Headache came on gradually and has since dissipated to 5/10, with nausea and dizziness resolving within two hours. Patient did not take anything for pain and reports only ingesting water since headache onset. Patient denied changes in vision, chest pain, shortness of breath, vomiting, diarrhea, constipation, seizures, edema, loss of consciousness. Patient denies recent travel, sick contacts, fever, chills, body aches, cough, sore throat.

 

Obstetric History: Full Term Induction due to pre-eclampsia x 1 (Child’s age 2)

Gynecologic History: None

PMH: pre-eclampsia in previous pregnancy

Medications: Prenatal Vitamins, Aspirin 81 mg once daily

PSH: denies

Allergies: denies

Family History: patient denies family history of cancer, diabetes, cardiovascular or lung disease but is unsure.

Social History: Never smoker. No EtOH use. No illicit drug use. Admits sexual activity with male partner, does not use contraception.

 

Review of Systems:

General: Admits 30 lb. weight gain in pregnancy. Denies fever, chills, night sweats, loss of appetite, weight loss, weakness, fatigue.

Skin, Hair, Nails: Denies change in texture, excessive dryness or sweating, discolorations, pigmentations, moles, rashes, pruritus, change in hair distribution.

Head: Admits headache. Denies trauma, loss of consciousness, coma, fracture, dizziness.

Eyes: Denies blurry vision, corrective lenses, visual disturbances, fatigue, photophobia, pruritus, lacrimation.

Ears: Denies deafness, pain, discharge, tinnitus, hearing aids.

Nose/Sinuses: Denies discharge, epistaxis, rhinorrhea, congestion.

Mouth/Throat: Denies bleeding gums, sore tongue, sore throat, mouth ulcers, voice changes.

Neck: Denies lumps, swelling, stiffness, decreased range of motion.

Breast: Denies lumps, nipple discharge, pain.

Respiratory: Denies dyspnea, shortness of breath, wheezing, cough, hemoptysis, cyanosis, orthopnea, paroxysmal nocturnal dyspnea.

Cardiovascular: Denies palpitations, irregular heartbeat, edema, syncope, chest pain, known heart murmur.

Gastrointestinal: Denies abdominal pain, change in appetite, intolerance to specific foods, nausea, vomiting, dysphagia, pyrosis, flatulence, eructation, diarrhea, constipation, hemorrhoids, change in stool, blood in stool.

Genitourinary: Denies frequency, urgency, hesitancy, nocturia, polyuria, oliguria, dysuria, change in urine color, incontinence, flank pain.

Musculoskeletal: Denies pain, deformity, swelling, redness, arthritis.

Peripheral Vascular: Denies peripheral edema, intermittent claudication, coldness or trophic changes, varicose veins, color change.

Hematologic: Denies anemia, easy bruising/bleeding, lymph node enlargement, history of DVT/PE.

Endocrine: Denies polyuria, polydipsia, polyphagia, heat or cold intolerance, goiter, hirsutism.

Neurologic: Denies seizures, loss of consciousness, sensory disturbances, paresthesia, ataxia, loss of strength, change in mental status, memory loss, asymmetric weakness.

Psychiatric: Denies feelings of helplessness/hopelessness, lack of interest in usual

activities, suicidal ideation, anxiety.

 

 

Physical Exam:

Vital Signs:

BP: 135/72

HR:84 bpm, regular

RR: 18 breaths/min, unlabored

Temp: 37.1C

SpO2: 99%RA

Ht: 64 inches

Wt: 155 lbs.

BMI: 26.6

 

General Survey: Patient lying comfortably in bed. No apparent distress.

Skin: No petechiae, masses, lesions.

Hair: Average quantity and distribution.

Nails: Capillary refill <2 seconds throughout.

HEENT: Head normocephalic, atraumatic, non-tender to palpation throughout. PERRLA, EOMs intact.

Cardiovascular: Regular rate and rhythm. S1 and S2. No murmurs, gallops, rubs.

Chest and Pulmonary: Chest symmetric, non-tender to palpation. No labored breathing or accessory muscle use. Clear to auscultation bilaterally.

Abdomen: Fundal height at 32 cm. Soft, non-tender. No guarding or rebound tenderness. Bowel sounds present, normoactive.

Vaginal Exam: Cervix closed, no blood in vaginal vault.

Extremities and Peripheral Vascular: Upper and Lower extremities symmetrical. No edema of bilateral upper and lower extremities. Peripheral pulses 2+.

 

Assessment:

KR is 20 yo G2P1001 female at 31w5d gestation by LMP with PMH significant for pre-eclampsia in prior pregnancy with induction of labor at term presenting with headache for 6 hours that was initially accompanied by dizziness and nausea without emesis but has since improved to 5/10 headache with no other signs or symptoms.

 

Plan:

# Rule out pre-eclampsia

• Serum uric acid, CMP, CBC, Urinalysis with urine culture, Urine protein, Urine microalbumin
• Fetal monitoring through tocometer
• Monitor blood pressure every 15 minutes

# Headache

• Tylenol PO

# Hydration

• Oral hydration, patient denied IV fluids

#Fetal Assessment

• Ultrasound

#DVT prophylaxis

• Pneumatic compression stockings