: Encounter for supervision of normal pregnancy
SAMPLE. 1: Encounter for supervision of normal pregnancy
S: SS is a 31-year-old G3T2P0A0L1 who is 22 and 2/7 weeks and presents for a routine pregnancy follow-up. She is a former smoker and takes prenatal vitamins. She denies cramping, bleeding, gushes or fluid, nausea, and vomiting. She has completed genetic testing and an anatomy ultrasound.
O: Weight 128 lbs., BP 118/68, HR 70
A: Fundal height measures 23 cm, Fetal heart rate 148 bpm
P: Discussed diet, exercise, and anticipatory guidance provided
-glucose tolerance test ordered for between 24-28 weeks
SAMPLE. 2
S: KS is a 34-year-old G0 female who presents for routine gynecologic exam. She has a history of PCOS and takes desogestrel-ethinyl estradiol daily as well as spironolactone 100mg daily. She has never been sexually active. No history of abnormal paps. Last pap in 2022 negative for HPV. She denies vaginal, breast, uterine symptoms. Reports regular monthly periods that last 3 days and are light. She denies dysmenorrhea. She is physically active, exercising 3 days a week. She denies ACHES does report an increase in facial hair.
O: Vitals: BP 112/80, weight 200 lbs, Obese
A: well-appearing, facial hair noted, thyroid gland not palpable, lungs clear bilaterally, unlabored, S1S2 without murmur, rate is regular, abdomen soft, nontender, trunchal obesity, vaginal walls rugated, cervix pink, without discharge, no CMT, uterus small mobile, no adnexal pain
P: RTO next year for annual exam -increase spironolactone to 100mg BID
SAMPLE 3
S: 33 y o female came to the office for prenatal visit. RH neg_ Rhogam given on january 25th. Hx of placenta previa-placenta clear
O: Vitals: BP 112/54, HR 78, weight 161.3, last week 160 lbs. Feels Ok, +FM, regular. No bleeding/LOF/CTX. FHR 134/min. Fundal height 38cm. Vertex
presentation Cervical exam: cervix long and closed US: 2830g, 13%ile. Hb 111
A: 28-week pregnancy Mild Fe deficiency anemia.
P: Fetal surveillance Feramax 150 mg PO OD IOL this Saturday-return to office in 4 weeks
