Physical assessment database
Patient Initials: MD
Date: July 14, 2013
Biographical Data: MD is a 32 year old white female currently living in blank. She is a stay-at-home mom with 2 living children and has been married for 8 years. She is 26 6/7 weeks pregnant.
History of Present Illness: MD has been hospitalized for preterm labor. This is her third hospitalization during this pregnancy for preterm labor. She has a MacDonald cerclage in place since 12 weeks gestation. She is experiencing irregular uterine contractions with uterine irritability noted to fetal monitoring strip. She is on bed rest with continuing fetal monitoring. She has Lactated Ringers infusing per peripheral catheter at 125ml/hr.
History of Past Illness: MD is a G4P2AB1, having miscarried at 8 weeks with a previous pregnancy. She delivered her living children preterm, one at 35 weeks gestation and the other at 34 2/7 weeks gestation, both vaginally. She completed steroid treatment to improve baby’s lungs at last hospitalization. She denies any significant health issues or previous surgeries. She states she is healthy with the exception of an incompetent cervix.
Childhood Diseases: MD reports having chicken pox around at 5. She reports having an occasional cold as a child with no memory of any serious illness. She states she did have an outbreak of poison ivy at less than 10 years old. Major adult illnesses: denies
Allergies: NKDA, no food allergies
Immunizations: MD states she is up-to-date on the influenza vaccine and TDAP. She received the TDAP after birth of last child, age 3. She has received the Hepatitis B series.
Medications: Home medications-
Prenatal vitamins, 1 tablet q day PO Hospital medications- Indocin 50mg PO q6h x 72 hours Stadol 1 mg IVP q4h PRN pain Phenergan 12.5mg q4h PRN to be administered with Stadol Lactated Ringers IV infusion at 125ml/hr.
Transfusions: denies
Emotional Status: MD denies previous diagnosis of any mental disorders. She states she is depressed and
Date: July 14, 2013
Biographical Data: MD is a 32 year old white female currently living in blank. She is a stay-at-home mom with 2 living children and has been married for 8 years. She is 26 6/7 weeks pregnant.
History of Present Illness: MD has been hospitalized for preterm labor. This is her third hospitalization during this pregnancy for preterm labor. She has a MacDonald cerclage in place since 12 weeks gestation. She is experiencing irregular uterine contractions with uterine irritability noted to fetal monitoring strip. She is on bed rest with continuing fetal monitoring. She has Lactated Ringers infusing per peripheral catheter at 125ml/hr.
History of Past Illness: MD is a G4P2AB1, having miscarried at 8 weeks with a previous pregnancy. She delivered her living children preterm, one at 35 weeks gestation and the other at 34 2/7 weeks gestation, both vaginally. She completed steroid treatment to improve baby’s lungs at last hospitalization. She denies any significant health issues or previous surgeries. She states she is healthy with the exception of an incompetent cervix.
Childhood Diseases: MD reports having chicken pox around at 5. She reports having an occasional cold as a child with no memory of any serious illness. She states she did have an outbreak of poison ivy at less than 10 years old. Major adult illnesses: denies
Allergies: NKDA, no food allergies
Immunizations: MD states she is up-to-date on the influenza vaccine and TDAP. She received the TDAP after birth of last child, age 3. She has received the Hepatitis B series.
Medications: Home medications-
Prenatal vitamins, 1 tablet q day PO Hospital medications- Indocin 50mg PO q6h x 72 hours Stadol 1 mg IVP q4h PRN pain Phenergan 12.5mg q4h PRN to be administered with Stadol Lactated Ringers IV infusion at 125ml/hr.
Transfusions: denies
Emotional Status: MD denies previous diagnosis of any mental disorders. She states she is depressed and