OB Care

#### HPI

{Patient here for routine OB visit.  No concerns today.}

{No} vaginal bleeding.  {No} loss of fluid.  {No} contractions.

#### Physical Exam

BP: {}

FHR: {}

{}

---

*Patient seen in the clinic for OB-related visit. 10 point ROS completed, all neg except as indicated. Patient was specifically asked about feeling contractions, vaginal bleeding, leakage of fluid, recent illness, fevers, chills, nausea, vomiting, dysuria or hematuria. The following exam was performed: Vitals reviewed. General appearance assessed. Neurologic gross assessed. HEENT assessed. Cardiovascular perfusion assessed. Respiratory status and effort assessed. Abdomen and Back visualized. Extremities assessed. Fetal heartrate assessed. Previous EMR records reviewed. Labs reviewed. Radiology results reviewed. Medication list was verbally reconciled with the patient, updated today. Depression screening performed with PHQ-2 on intake; Safety assessment performed with safety question on intake; All screeners negative unless discussed.*

---

### Contact Information

{}

### Screening / Preventive Medicine History

Last PAP: {}

{}

### Medical History

{}

### Previous Pregnancy History

G{}P{}

- {date}: {} wga {SVD/LTCS}: {weight} {sex}; {length labor}; {pain mgmt}; @ {location}; {no complications}

### Surgical History

{}

### Infectious Disease History

{No history of TB exposure or positive PPD}

{No hx of HSV}

{No hx of other STI}

### Mental Health History

{No history of depression}

{No hx of domestic abuse/FAP case}

### Social History

{}

{|Married||Single|}

Father of the baby is {|involved||not involved|}

{Home safety discussed at first OB visit, patient felt safe}

{Patient has no history of illicit substance use or abuse}

{Never smoked/vaped/dipped}

{Social EtOH before pregnancy, quit once pregnant}

### Patient's Family History

{}

### Paternal (Father of Baby) Medical & Family History

{}

### Genetic Abnormality Screening

{|Desires||Declines||Previously Completed|} Cystic Fibrosis screening

{|Desires||Declines|} Aneuploidy screening (Integrated Screen / Quad Screen / Cell-Free DNA)

### LAB SUMMARY

```

    -- Initial:

        ...Blood Type  {|A||B||AB||O|} {|(+)||(-)|}

        ...Antibody    {|negative||positive|}

        ...Hgt/HCT     {} / {}

        ...MVC         {} 

        ...Platelets   {}

        ...RPR         {negative}

        ...HBsAg       {negative}

        ...Rubella     {immune}

        ...Varicella   {|immune by lab||immune by history|}

        ...HIV         {negative}

        ...Urine Cult  {no growth}

        ...Gonorrhea   {negative}

        ...Chlamydia   {negative}

        ...Hg Ephores  {not indicated} (if indicated for AA, or mediterranean + anemia)

        ...HTLV 1/2    {not indicated} (if indicated)

        ...CF          {|negative||declined|}

        ...IS/Quad     {} (at 15-16 weeks (definitely before wk 22) if desired)

    -- 8-18 week:

        ...A1c         {} (Early A1c or GTT for BMI>30 + risk factor: sedentary, famhx etc...)

        ...1hr GTT     {}

        ...3hr GTT     {} (if 1hr > 140)

    -- 24-28 week:

        ...Hgb/HCT     {} / {} (if intake showed anemia)

        ...MCV         {}

        ...WBC/Plat    {} / {}

        ...1 hr GTT    {} (at 28+ wga)

        ...3hr GTT     {} (if 1hr > 140)

    -- 35-37 week:

        ...GBS swab    {}

```

### Ultrasounds

First Trimester dating ultrasound:

- performed on {date}:

- {|Transabdominal||Transvaginal|}

- {Single Intrauterine Pregnancy visualized}

- LMP WGA: {}

- Ultrasound CRL:  {}

- Ultrasound WGA: {}

- {Size equal to dates.}

### Miscellaneous

EDPS 

- Intake: {}/30

- 24-28wga: {}/30

TDaP: {plan to give at 27+ wga}

Flu vaccine: {plan to give when available}

{PPD: placed {date}, read: {date}}

### Medication Allergies

{}

### Current Medications

{}

### This Pregnancy / Problem List

EDD: **{}** {|by LMP||by LMP c/w FTUS||by US|}}

LMP: {}

#### Assessment and Plan

## G{}P{} at {}+{}

## {Routine pregnancy}

## {|Yokosuka||Murakami||CONUS|} for delivery

Getting outside OB care from {|Murakami||Sogo|}.

- {Continue routine pregnancy care}

#### Follow-Up: {}

---

#### HPI

{No current concerns. }

{No} vaginal bleeding.  {No} loss of fluid.  {No} contractions.  

---

*Additional Information:  Patient seen in the clinic for OB-related visit. 10 point ROS completed, all neg except as indicated. Patient was specifically asked about feeling contractions, vaginal bleeding, leakage of fluid, recent illness, fevers, chills, nausea, vomiting, dysuria or hematuria. The following exam was performed: Vitals reviewed. General appearance assessed. Neurologic gross assessed. HEENT assessed. Cardiovascular perfusion assessed. Respiratory status and effort assessed. Abdomen and Back visualized. Extremities assessed. Fetal heartrate assessed. Previous EMR records reviewed. Labs reviewed. Radiology results reviewed. Medication list was verbally reconciled with the patient, updated. Depression screening performed with PHQ-2 on intake; Safety assessment performed with safety question on intake; All screeners negative unless discussed.*

---

{,q-rob-hx-chrispebble}

---

#### Physical Exam

BP: {}

FHR: {}

{}

---

#### Assessment and Plan

## G{}P{} at {}+{}

## EDD: {date} {by LMP c/w FTUS}

## {Routine pregnancy}

## {|Yokosuka||Murakami||CONUS|} for delivery

Getting outside OB care from {|Murakami||Sogo|}.

- {Continue routine pregnancy care}

#### Follow-Up: {}

---

#### HPI

{Patient presents for initial OB dating ultrasound.  No concerns today.}

LMP was {date}.

{|Desires||Declines||Previously Completed|} Cystic Fibrosis screening

{|Desires||Declines|} Aneuploidy screening (Integrated Screen / Quad Screen / Cell-Free DNA)

---

### Ultrasounds

First Trimester dating ultrasound:

- performed on {date}:

- {|Transabdominal||Transvaginal|}

- {Single Intrauterine Pregnancy visualized}

- LMP WGA: {}

- Ultrasound CRL:  {}

- Ultrasound WGA: {}

- {Size equal to dates.}

---

#### Assessment & Plan

## G{}P{} at {}+{}

## EDD: {date} {by LMP c/w FTUS}

- {}

#### Follow-Up: {}

*Above note reviewed. Patient seen in the clinic for initial OB dating ultrasound. 10 point ROS completed, all neg except as indicated. Patient was specifically asked about feeling contractions, vaginal bleeding, leakage of fluid, recent illness, fevers, chills, nausea, vomiting, dysuria or hematuria. The following exam was performed: Vitals reviewed. General appearance assessed. Neurologic gross assessed. HEENT assessed. Cardiovascular perfusion assessed. Respiratory status and effort assessed. Abdomen and Back visualized. Extremities assessed. Fetal heartrate assessed. Previous EMR records reviewed. Labs reviewed. Radiology results reviewed. Medication list was verbally reconciled with the patient, updated. Depression screening performed with PHQ-2 on intake; Safety assessment performed with safety question on intake; All screeners negative unless discussed.*