Pregnancy evaluation

Age [text]

G [text]
T [text]
P [text]
A [text]
L [text]

EDC [text]
Gest Age [text]

SUBJECTIVE
Reason for Visit: 
[radio name="ChiefComplaint" value="Prenatal Checkup|Abnormal Bleeding|Abdominal Pain|Low Fetal Movement|Other"]
[text name="variable_1" default=""]

MEDICATIONS:
allergies reviewed
[checkbox name="medications" value="taking OTC|taking ABX|not taking any medications|taking meds for chronic condition|"][textarea cols=40 rows=5]

PMH:
[textarea cols=80 rows=1 default="Complications with previous pregnancy:"]
[textarea cols=80 rows=1 default="Complications with previous delivery:"]
[textarea cols=80 rows=1 default="Complications with current pregnancy:"]
[textarea cols=80 rows=1 default="Previous Surgeries/Hospitalizations:"]


Review of Systems:
Pregnancy Associated Symptoms:
[checklist name="PregnancyAssociatedSymptoms" value="nausea|vomiting|dysuria|vaginal pain|none"]

[textarea cols=80 rows=1 default="CONSTITUTIONAL: denies fever, chills, fatigue"]
[textarea cols=80 rows=1 default="SKIN: denies rashes, bruising, itching nail or hair changes"]
[textarea cols=80 rows=1 default="EYES: denies blurring/double vision/spots/changes in vision."]
[textarea cols=80 rows=1 default="THROAT: denies pain/trouble swallowing."]
[textarea cols=80 rows=1 default="NECK: denies painful or swollen nodes."]
[textarea cols=80 rows=1 default="ENDOCRINE: denies tremor/palpitations/heat or cold intolerance/unusual fatigue; denies polyuria/polydipsia/polyphagia"]
[textarea cols=80 rows=1 default="RESPIRATORY: denies cough/sputum/SOB/chest pain."]
[textarea cols=80 rows=1 default="CARDIOVASCULAR: denies CP/heaviness/jaw or arm pain/palpitations/leg pain with exercise/edema."]
[textarea cols=80 rows=1 default="GASTROINTESTINAL: denies constipation/nausea/vomiting/diarrhea/blood in stool/RUQ pain/abdominal trauma."]
[textarea cols=80 rows=1 default="GENITOURINARY: denies dysuria/frequency/vaginal bleeding/vaginal pain/leaking of fluid/blood in urine/incontinence"]
[textarea cols=80 rows=1 default="BREASTS: denies tenderness, nipple discharge, lumps, swelling."]
[textarea cols=80 rows=1 default="MUSCULOSKELETAL: denies pain/swelling in muscles or joints."]
[textarea cols=80 rows=1 default="NEUROLOGICAL: denies weakness, numbness/tingling, headache, or other pain."]
[textarea cols=80 rows=1 default="PSYCHIATRIC: denies depression/anxiety/hallucinations"]
[textarea cols=80 rows=1 default="SOCIAL: denies tobacco, alcohol, or recreation drug use"]


OBJECTIVE 

[textarea cols=80 rows=1 default="Vitals BP: , P: , RR: , T: , SpO2:"]

Exam
[textarea name="variable_2" cols=80 rows=2 default="GENERAL APPEARANCE: Well developed, well nourished, alert and cooperative, and appears to be in no acute distress, pregnant."]
[textarea name="variable_3" cols=80 rows=1 default="HEAD: normocephalic. Atraumatic."]
[textarea name="variable_4" cols=80 rows=1 default="EYES: PERRL, EOMI."]
[textarea name="variable_8" cols=80 rows=1 default="NECK: No JVD. No thyromegaly."]
[textarea name="variable_9" cols=80 rows=3 default="CARDIAC: Normal S1, S2. No S3, S4 or murmurs. RRR. No peripheral edema, cyanosis or pallor. Cap refill  <2 s."]
[textarea name="variable_10" cols=80 rows=2 default="LUNGS: CTA. No rales, rhonchi, wheezing or diminished breath sounds."]
[textarea name="variable_11" cols=80 rows=2 default="ABDOMEN: Positive bowel sounds. Soft, nontender, pregnant."]
[textarea name="variable_12" cols=80 rows=2 default="MUSKULOSKELETAL: No joint erythema or tenderness. Normal muscular development. Normal gait."]
[textarea name="variable_14" cols=80 rows=2 default="EXTREMITIES: No significant deformity or joint abnormality. No edema. Peripheral pulses intact. No varicosities."]
[textarea name="variable_16" cols=80 rows=2 default="NEUROLOGICAL: No focal deficits noted. Strength and sensation symmetric and intact throughout."]
[textarea name="variable_17" cols=80 rows=1 default="SKIN: Skin normal color, texture and turgor with no lesions or eruptions."]
[textarea name="variable_18" cols=80 rows=1 default="PSYCHIATRIC: Normal mood and affect."]
[textarea name="variable_21" cols=80 rows=1 default="BREASTS: Soft. No masses, tenderness, asymmetry, nipple discharge or axillary lymphadenopathy."]
[textarea name="variable_22" cols=80 rows=3 default="PELVIC: Normally developed external female genitalia with no external lesions or eruptions. Vagina and cervix have no lesions, inflammation, discharge or tenderness. 0/0/-3"]

[text name="variable_1" default="FHT:"]
[text name="variable_1" default="Fundal Height"]


Labs:
[textarea name="variable_1" default="Blood type:
Rhogam given: N/A
RPR: NR
HIV: Neg
Rub: Imm
HepB: Neg
GBS: NOT TESTED
Covid: NOT TESTED"]


ASSESSMENT/PLAN:
[textarea default="1.Encounter for supervision of normal pregnancy, unspecified, unspecified trimester"]

[textarea name="variable_1" default="Labs/Tests/Procedures"]

[checklist name="variable_1" value="dating US|1st trim screen wk10-13|nuchal translucency wk11-14|amniocentesis wk14-18|quad screen wk16-18|2nd trimester anatomy scan wk18-20|HGBA1C|FG|EDS|GBS wk36|repeat H/H wk24-28|2 hour GTT wk24-28|tdap 3rd trim|Prenatal labs routine|PIH labs"]


Education:
[textarea default="1)Continue prenatal vitamins. 2)Reviewed birthing plan. Education provided about signs and symptoms of labor and when to report to labor and delivery if there is expected labor.3)Reviewed healthy lifestyle issues including weight loss, diet, and exercise.4)Reviewed safety issues including wearing seatbelts, avoiding talking/texting while driving and gun safety in the house.

Call provider if you experience chest pain, SOB, fever >101.4, N/V/D, visual changes, headache unrelieved by medication. Contact provider if you have vaginal bleeding, leaking fluid (gush/trickle), decreased movement of baby."]

[textarea name="variable_1" default="Follow Up:"]