Tina Sandler – PART 2 – OBGYN Diagnosis – Prenatal checkup (Pregnancy) – Domestic Violence Prenat checkup 24w, fall (DV), headache, constipation, hx preeclampsia, hx ectopic preg, hx intrauterine fetal demise, PE – bruise LLQ abd, PE – bruise l breast Tests- obs us, UA, CBC, TSH Problem Statement: ( Demographic description – chief complaint – Hx and PE key findings – risk factors )
Tina Sandler is a G5P1 woman presenting at 24weeks gestation for prenatal checkup. She reports falling in a domestic altercation with her intoxicated husband. On physical exam she has a large bruise in her abdomen LLQ, hyperechoic sounds are heard in her abdominal RUQ, fetal heart rate is 140, there is also a 5x5in bruise on her left breast. She reports new headaches and ankle edema on standing. Patient hasa history of ectopic pregnancy and preeclampsia and 3rd trimester loss of pregnancy.
CC: Tina Sandler is a 29 year old G5P1 woman presenting at 24 weeks gestation for prenatal checkup She reports falling in a domestic altercation with her intoxicated husband. HPI: Patient reports in a fight with her husband she ‘fell down the stairs’ - On physical exam she has a large bruise in her abdomen LLQ, hyperechoic sounds are heard in her abdominal RUQ, fetal heart rate is 140, there is also a 5x5in bruise on her left breast. She reports new headaches and ankle edema on standing. She describes her headaches as new and starting in the mornings. Meds: Prenatal vitamins PMH: Patient has a history of ectopic pregnancy and preeclampsia and 3rd trimester loss of pregnancy. SH: Patient reports that she is not currently smoking cigarettes, drinking alcohol, or using recreational drugs while pregnant ROS: Only positive findings are seen in HPI Physical Exam: VS: Pulse – 78; BP – 118/78 RR – 14; T – 98.6F (37 C); SpO2 – 94% Abdomen: A large bruise (4 – 6cm) is seen in LLQ – fetal movement is palpated, fetal heart rate 140bpm. Hyperechoic sounds are heard on auscultation of RUQ of abdomen. Chest: A large bruise is seen on the Left breast Gynecologic: Speculum exam shows no bleeding. ASSESSMENT/PLAN