H&P for Triage - Admitted or Discharged

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H&P for Triage Patient

CHIEF COMPLAINT: []

HPI:

[] yo G[]P[] at [] []/7 wga by [last menstrual period consistent with ][] week ultrasound who presents to labor and delivery triage with []. Patient denies contractions, vaginal bleeding, loss of fluids. She reports [normal] fetal movement.

Pregnancy complicated by []. Patient has been receiving prenatal care with Dr. [].

Estimated due date []. Last menstrual period [].

Has/Has not received Covid Vaccine. [ how many doses? booster?]

OB HISTORY:

G1 [year] [vaginal or c/s] at [] weeks. [Gender] [baby weight], [no complications]

G2 [year] [vaginal or c/s] at [] weeks. [Gender] [baby weight], [no complications]

G3 [year] [vaginal or c/s] at [] weeks. [Gender] [baby weight], [no complications]

G4 [year] [vaginal or c/s] at [] weeks. [Gender] [baby weight], [no complications]

GYN HISTORY:

Menses: menarche at [], periods [regular], lasting [] days

STDs: patient reports [no] history of STIs, [consistent with chart review]

Abnormal Paps: patient [denies] abnormal pap smears

PMH: [denies]

PSH: [denies]

FAMILY HISTORY: [Denies family history of birth defects or genetic disorders], [denies family history of bleeding or clotting disorders]

SOCIAL HISTORY: [Denies] tobacco, alcohol, or illicit drug use; [intimate partner violence screening negative]

MEDICATIONS: [Prenatal vitamins]

ALLERGIES: [NKDA] [(reaction)]

ROS: [All systems reviewed and negative except as noted in HPI.]

PHYSICAL EXAM: [Vital signs reviewed]

BMI: []

Gen: [Alert and awake]

HEENT: [Normocephalic, no periorbital edema]

CV: [Warm and well perfused]

Resp: [Aerating well, symmetric expansion]

Abd: [Soft, gravid]

Pelvic: [Adequate] pelvis, EFW []#, cervix []/[]/[] Extremities: [No] edema on lower extremities

Skin: [Supple, intact, no rashes]

Neuro: [Alert & oriented x3]

MEDICAL DECISION MAKING:

Prenatal Labs: [Blood type]/[Antibody screen], R[I], RPR[NR], HIV[-], HBV[-], HCV[-], GC/CT[-], 1hr GTT [], GBS[-]

External fetal heart tracing: Baseline HR [] with moderate variability, accelerations, [no] decelerations

Tocometry: q[] min contractions

Bedside U/S: [cephalic]

[Labs/Imaging/Studies]

ASSESSMENT: [] yo G[]P[] at [] []/7 wga by [last menstrual period consistent with ][] week ultrasound who presents to labor and delivery triage with [].

2. [Not in ]active labor

3. Reassuring fetal status

4. Cephalic presentation

5. GBS[]

PLAN: [DISCHARGE FROM TRIAGE]

- Discharge to home

- Labor precautions reviewed

- Pre-eclampsia precautions discussed

- Follow up with primary obstetrician

- Red flags to call MD or return to hospital discussed with patient who voiced understanding

- Plan of care reviewed with patient and questions answered

- Patient care plan discussed with attending physician, Dr. []

PLAN: [ADMIT FROM TRIAGE]

- Admit to labor & delivery for []. [The patient was counseled on the slightly increased risk of fetal morbidity/mortality at this gestational age, however, the benefits of delivery prior to 39 weeks outweigh the risks at this time.]

- R/B/A reviewed and consents obtained for blood, delivery[, and Cytotec]

- Admit labs drawn

- Continuous fetal heart rate and contraction monitoring

- [Start Pitocin as clinically indicated]

- [Consult anesthesia for epidural as requested by patient]

- Labor & delivery course discussed with patient; questions answered

- Patient care plan discussed with attending physician Dr. []