CONPH NSG63
3
0/NSG64
3
0 Subjective, Objective, Assessment, Plan (SOAP) Notes
0
8
2023 Student Name:
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FAMILY HISTORY (must complete this section) M: MGM:
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Differential Diagnoses •
Diagnosis, (ICD 10 code and reference):
•
Diagnosis, (ICD 10 code and
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Diagnosis •
Presumptive diagnosis (ICD 10 code and reference):
Plan/Therapeutics: Diagnostics: Education Provided: Dina Meissner
NSG 6430
CB
10/10/23
1000
White
25
Female
I have been experiencing spotting and I am 9 weeks pregnant
CB is a 25 year old female G1P0 who presents to the office today with c/o brown and red vaginal bleeding. she is currently 9 weeks pregnant and reports that the spotting is not enough to saturate a pad but reports noticing blood while wiping with toilet paper of the past 2 days. pt denies any cramping of passing any products of conception. Prenatal vitamins
N/A
None
None
N/A
Wisdom teeth 2016
Living, H/o Depression
Living, h/o HTN and CKD
Living, h/o colon cancer
Living, h/o CHF
Living, h/o DM2
Living, h/o DM2
Pt reports drinking socially. denies any smoking
healthy well appearing 25 year old female
denies any palpitations, cp, or orthopnea
no bumps, lumps or lesions
denies any SOB
no change in vision or corrective lenses
denies any n/v/d or changes in stool. No abdominal tenderness denies any ear pain
Pt reports brown and red vaginal spotting over the past 2 days. pt denies enough blood to saturate a pad but reports noticing the discharge when denies any nose, mouth or throat pain. no redness or swelling noted
pt denies any pain or problems with movement
no lumps bumps or changes
no acute or chronic neurological changes
no lymphadenopathy noted
no psychiatric history
145lb
5ft3in
25.7
120/68
98
82
19
Pt is normal weight and in no acute distress. pt appears well groomed
skin is warm, dry, and intact. no rashes or lesions noted
The head is normal-shaped. PERRLA eyes, anicteric sclera, no conjunctival pallor, and supple neck. complete range of motion, no cervical lymphadenopathy, and no occipital nodes. neither nodules nor thyromegaly. Pink and moist oral mucosa. No tumors or dental anomalies in
S1, S2 with regular rate and rhythm. No extra sounds, clicks, rubs or murmurs. Capillary refill 2 seconds. Pulses 3+ throughout. No edema.
symmetric chest wall. Respirations are regular and easy; lungs clear to auscultation bila
symmetrical with normal bowel sounds in each of the four quadrants. Soft abdominal wall, no distention, or epigastric discomfort. No sensitivity for rebounding or defending. Hernia, hepatosplenomegaly, or no masses.
breast is free from masses or tenderness, no discharge, no dimpling, wrinkling, or discoloration of the skin.
No rashes or abnormal vaginal discharge noted. Pt noted to have to get up and urinate frequently. Urine seems cloudy and foul smelling
while observing the patient move about the examination room, full range of motion was noticed in all four extremities. No cyanosis or clubbing or edema. The skin and extremities appear to be well-perfused.Pt c/o 4/10 low back pain and seemed to have trouble finding a comfortable position
speech is clear. good tone. balance stable. gait normal
riented and alert. capable of keeping eye contact.
beta hcg
Ultrasound
Spontaneous abortion O03.9
Subchorionic hematoma O46.9
Ectopic pregnancy O00.9
Subchorionic hematoma O46.9
Spotting in early pregnancy happens in about 20% of pregnancies. the patient Blood accumulates close to the chorion, the fetal membrane adjacent to the placenta, resulting in a subchorionic hematoma. Additionally, there may be bleeding between the uterus and the placenta. This could also be referred to as a subchorionic hemorrhage by some persons. The majority of episodes of bleeding in the first trimester of pregnancy—about 11% of them—are caused by subchorionic hematomas. A subchorionic Ultrasound to check for viability of pregnancy and beta hcg to ensure that the number correlates with the 9 weeks of pregnancy
The patient was educated that a subchorionic hematoma is bleeding around the membrane of the uterus. she was educated that it is a common cause for bleeding and that the US done in office showed that the fetus was still viable. she was instructed to call the office back if she experiences dizziness, worsening bleeding, passing tissue, fever, or pelvic pain. she was instructed to return to the office in 1 one to repeat the ultrasound a beta hcg. References
Naert, M. N., Khadraoui, H., Muniz Rodriguez, A., Naqvi, M., & Fox, N. S. (2019). Association Between First-Trimester Subchorionic Hematomas and Pregnancy Loss in Singleton Pregnancies. Obstetrics & Gynecology, 134(2), 276–281. https://doi.org/10.1097/aog.0000000000003360
Yan, X., Xu, H., Li, J., Xu, Z., Niu, Y., & Wang, Y. (2023). Subchorionic hematoma and risk of preterm delivery: a systematic review and meta-analysis. American Journal of Obstetrics & Gynecology MFM, 5(1), 100791. https://doi.org/10.1016/j.ajogmf.2022.100791
(Naert et al., 2019)
(Yan et a
