G6T2P1A2L2, LMP 08/19/2024, EDD: 05/26/2025, who presents today, 1/27/25,
S:
Chief Complaint: Prenatal Visit –
This is a 30-year-old Caucasian female G6T2P1A2L2, LMP 08/19/2024, EDD: 05/26/2025, who presents today, 1/27/25, for a prenatal visit, She reports having one complication during previous pregnancies, which resulted in preterm labor; she had regular vaginal deliveries 2 and 4 years ago, resulting in healthy female and male infants weighing 3.3 kg and 3.2 kg, respectively. She experienced two miscarriages in the past two years, one preterm labor, and her current pregnancy is planned. No genetic testing was conducted.
O: + VSS: No fever + Skin: No unusual lesions or nevi; warm and dry. + External genitalia: Normal female-pattern hair distribution; no lesions or erythema on labia minora, Majora, or introitus. + Vagina: Pink walls with present rugae; no lesions or tears; well estrogenized; serosanguinous discharge noted. + Cervix: Pink and smooth; no lesions, discharge, or bleeding; no polyps or pain. + Fundal height measures 24 cm; FHR 134/min. +FM is regular. Bedside ultrasound shows a single viable fetus in the transverse position with a posterior placenta. Low heartbeat at 89. Breast exam: Right breast inspection shows no nipple discharge, skin discoloration, rashes, dimpling, retraction, tenderness, or masses; no lymphadenopathy. Left breast inspection reveals no nipple discharge, skin discoloration, rashes, dimpling, retraction, tenderness, or masses; no lymphadenopathy. Palpation: Right breast non-tender; axillae free of lymphadenopathy or palpable masses. Left breast non-tender; axillae free of lymphadenopathy or palpable masses.
A: 23 weeks pregnant; diagnosed with iron-deficiency anemia. Diagnostic: bedside ultrasound.
P: Scheduled for a hematology appointment next week to address anemia. Discuss topics including nutrition, weight gain, exercise, smoking cessation, alcohol use, domestic violence, and immunizations.
Pharmacologic: Polydextrose-iron complex (Feramax 150 mg PO OD). Prenatal vitamin
Non-pharmacologic: Provided education on exercise, fluid intake, prenatal vitamins, and nutrition management. RTC in 4 weeks.
This is just a sample; don’t use these medications. NOTE:
Pharmacology interventions MUST BE IN THIS FORMAT
Ciprofloxacin (Cipro) 500 mg tablet orally every 12hrs for seven days
Acetaminophen 650 mg tablet orally every 4-6 hours as needed.
Ondansetron (Zofran) 8 mg tablet orally every 12 hours as needed for seven days.
APA FORMAT, AND REFERENCES, peer review scholarly resource cited in APA format from 2020-2025 only. (Within the last five years)
Please do not solely use a website as your scholarly reference. It is fine to use it as a supplement, but a journal article or text should be referenced.
Please use North American peer-reviewed journals ONLY.
DO NOT use any European Journal
Please use reliable medical references such as the Current Medical Diagnosis and Treatment book or UpToDate. Do not use WebMD, Wikipedia, etc., as these are not advanced practice references.
APA format (if using outside sources).
