RP, a 27-year-old G3T1P0A1L1 at 37 weeks gestation presenting for a routine prenatal visit. She reports symptoms consistent with an upper respiratory infection
S: “ I wound like GYN Annual visit.” Date of examination
EJ , a 21-year-old Caucasian female, G-0. LMP: 1/11/2025. Present for routine annual GYN visit. Menarche at age 12, regular, menses regular cycle every 29 days, lasts 5-7 days, Last coitus 3 days ago. She complains of pelvic discomfort. She notices pelvic discomfort mostly during sex. Recently became sexually active. Has not been using condoms. would like to start OCP and was previously taking OCP, both Tri-Sprintec and Norethindrone, which gave her some side effects. Would like to resume back to birth control. Denies vaginal urinary or bowel changes; patient reports occasional pelvic pain, which had a sonogram completed 2 weeks ago and was told that the pain is associated with gas.
O: Vital Signs: Wt. 100 lbs. Ht: 60 in. BMI: 19.5 kg/m2. BP: 116/83 mmHg. HR: 96 bpm. RR: 18 bpm. T: 97. 6°F, Spo2: 98% RA.
Constitutional: General Appearance: Well-appearing, well-groomed, bright affect. Appears stated age. Cooperative and answers questions appropriately.
Skin: Warm, dry, intact. No unusual bruising or suspicious lesions or moles.
HEENT: Head: normocephalic and atraumatic. Face: symmetric. Eyes: Sclera white, no
discharge. Conjunctiva pink.
Cardiovascular: Regular rate and rhythm, s1 and s2 present, no murmurs, rubs, or gallops.
Respiratory: Lungs CTA bilaterally. No rhonchi, rales, or wheezes.
Lymph Nodes: No cervical, axillary, or epitrochlear nodes
Breasts Exam : B/L breast No change in the skin of the breast, no breast swelling, No retraction of the nipple. No deviation of the nipples. No abnormal secretion, No palpable masses bilaterally. No tenderness. No diffuse fibrous tissue.
Abdomen: Abdomen soft, non-distended, and non-tender. No CVA tenderness.
Pelvic Exam: External Genitalia: Hair distribution of normal female pattern. Vulva, labia majora, labia minora, and introitus are pink and moist without lesions or erythema. Perineum without lesions. No inguinal lymphadenopathy. Vagina: Walls pink and moist, rugae present, no lesions/tears, no odor, no discharge in the vaginal canal. Good tone. Cervix: Pink, smooth, mobile, without lesions, bleeding, or polyps. no discharge present. (Sureswab collected at this time).. Uterine: Uterus small, anteverted, midline, mobile, soft, non-tender. Negative CMT
Adnexae: No adnexal enlargement, tenderness, or masses palpated bilaterally. Wet Prep: Wet preps are not done at the clinical site. (based on age Wet test is not required )
Diagnostics:
1. Laboratory Tests:
· Complete Blood Count (CBC): Evaluate for anemia or infection.
· Urinalysis by dipstick: Urine protein negative, glucose negative, and leukocyte esterase negative.
· Pregnancy Test: Urine pregnancy test and negative.
· UA culture clear UPT Negative, CBE and pelvic exam WNL, PAP Smear collected, STD cultures collected
2. Imaging:
· A pelvic ultrasound performed: Multiple slices through the pelvis utilizing transvaginal approaches using 2D and 3D
· The uterus is Anteverted and has a Normal appearance.
· The uterus measures 7.15 x4.42 x3.7cm. The uterine volume= 37.59ml.
· There is no evidence of myomas. 3D construction shows a normal contour of the endometrial cavity and myometrium.
· The endometrial cavity has a Normal appearance and measures 9.51 mm.
· The cervix has a normal appearance. The cul de sac shows No fluid collections.
· The right ovary measures 4.52 x3.14 x1.95cm and has Multiple Follicles.
· The left ovary measures 3.3 x1.3 x1.43cm and has a normal appearance.
· No adnexal masses.
Assessment:
· Visit for gynecological exam without abnormal findings
· Encounter for contraceptive pill surveillance
Plan:
· Medications:
· Loestrin Fe 1/20 1-20 mg-mcg tablet, take one tablet by mouth daily x 28 days
Education:
· Procedures: PAP Smear.
· Education:
Educated the patient that the first 21 tablets contained hormones (active pills).
And that the last seven tablets contain iron (inactive pills), during which a withdrawal bleed (similar to a monthly period) may occur.
Educated her to Swallow the tablet whole with water. It can be taken with or without food.
Missed Dose education provided:
· Missed one active pill: Take it as soon as you remember, even if that means taking two pills in one day. Continue with the pack as usual.
· Missed two consecutive active pills: Take two pills as soon as possible and then take two more pills the following day. Use backup contraception, such as condoms, for at least 7 days.
· Missed three or more active pills: Discard the current pack and start a new one immediately. Use backup contraception for 7 days.
· Missed placebo pills (iron pills): There is no need to worry. Continue taking the pills as scheduled.
· Educate on safe sex practices/condoms, discussed different forms of birth control, including pills, patches, injections, IUDs,
· Advised foreplay, lubrication, and change in sexual positions.
· Education on ACHES: Abdominal Pain, Chest Pain, Headaches, Eye Problems, Severe Leg Pain or Swelling that can be associated with contraceptives, and when to seek emergency care
Follow-up: RTC in 2 weeks for results of PAP smear and STI/STD.
· RTC in 3 months for OCP surveillance and 1 year for annual exam or PRN
Referral:
· PCP for health maintenance
· GI for occasional abdomen discomfort.
S – “I would like STD testing”
SJ, a 22 y.o. Caucasian female, G-0, LMP 6/6/23, BC – Nuvaring, presents for STD testing. Believes her new BF is cheating on her and would like full STD screen. Has noticed a yellow, malodorous d/c. Denies itching, fever, pelvic or abd. pain. Has not been using condoms. Menses regular. Last coitus – ~5days ago. H/O Chlamydia in 2022 – both partners treated. Note: I am not repeatedly writing “pt. states” – no need for complete sentences. Every note should start with this information!!
O: Vital Signs: Wt:115 lbs Ht: 60 in. BMI: 22.5 BP:102/72 HR:78 RR18: T: 98.6 SPO2: 99% on RA. Constitutional: General Appearance: Well-appearing, well-groomed, bright affect. Appears stated age. Cooperative and answers questions appropriately. Skin: Warm, dry, intact. No unusual bruising or suspicious lesions or moles. HEENT: Head: normocephalic and atraumatic. Face: symmetric. Eyes: Sclera white, no discharge. Conjunctiva pink. Cardiovascular: Regular rate and rhythm, s1 and s2 present, no murmurs, rubs, or gallops. Respiratory: Lungs CTA bilaterally. No rhonchi, rales, or wheezes.
Breast exam deferred. Note: if no exam done, document that it was deferred. Abdomen: Abdomen soft, non-distended, and non-tender. No CVA tenderness. Pelvic Exam: Note: documentation is working from outside >>>in External Genitalia: Hair distribution of normal female pattern. Vulva, labia majora, labia minora, and introitus are pink and moist without lesions or erythema. Perineum without lesions. No inguinal lymphadenopathy. Vagina: Walls pink and moist, rugae present, no lesions/tears, no odor, moderate amount of yellow discharge in the vaginal canal. No prolapse noted. No cystocele or rectocele noted. Good tone. Cervix: Pink, smooth, mobile, without lesions, bleeding, or polyps. Yellow discharge present. (Sureswab collected at this time).. Uterine: Uterus small, anteverted, midline, mobile, soft, non-tender. Negative CMT (Note: CMT is documented with uterine exam as this is assessed with the bimanual) Adnexae: No adnexal enlargement, tenderness, or masses palpated bilaterally. Urine HCG-Negative Wet Prep: Clue Cells: Positive. pH: 6.0. Hyphae/spores: Negative. Whiff: Positive. Trich: Negative. If wet preps are not done at your clinical site, indicate that you would have done one! A: Bacterial Vaginosis, STD Screening P: Rx – Flagyl 500mg. 1 tab po BID x 7 days (Written in prescriptive language) -Sureswab Plus (tests for GC/CT, BV, Yeast and Trich), RPR, HIV, Hepatitis b +c, -Safe sex education, condoms given. Advised re: No ETOH
-Reviewed ACHES -ALWAYS document this with hormonal contraceptives -Will call with results and base further treatment on results -Call if have any fever, chills, nausea, vomiting, flank pain.
CC: prenatal revisit-
S: RP, a 27-year-old G3P0A1L1 at 37 weeks gestation presenting for a routine prenatal visit. She reports symptoms consistent with an upper respiratory infection, including congestion, mild cough, and rhinorrhea. No fever, chills, dyspnea, or chest pain. No contractions, leakage of fluid, or vaginal bleeding. Good fetal movement was noted.
O:VS: BP: 128/88 mmHg (right arm, seated), Heart Rate: 62 bpm Respiratory Rate: 17 breaths per minute, Temperature: 98.6°F, Spo2: 100%, Room air G3 T0P0A1L1. Gestational Age: 37 weeks, Fundal Height: 37 cm, Fetal Movement: Positive, Fetal Heart Rate (FHR): 147 bpm, reassuring, GBS Status: Negative
A: 37 weeks gestation, routine prenatal visit. Upper respiratory infection, likely viral etiology, COVID-19 swab test was performed, No signs of labor or obstetric complications.
P: Supportive care for URI includes increasing hydration, getting plenty of rest, using steam inhalation, applying saline nasal spray, and taking acetaminophen as needed for fever or discomfort. Pregnant individuals should avoid decongestants.
Monitor symptoms carefully. Return to the clinic if the fever persists (above 100.4°F), if symptoms worsen, or if fetal movement is decreased.
Routine prenatal care requires a clinic visit in 1 week for fetal monitoring and ongoing prenatal evaluation.
Labor precautions involve counseling on signs of labor, such as contractions, rupture of membranes, or decreased fetal movement, and guidance on when to go to labor and delivery.
The post RP, a 27-year-old G3T1P0A1L1 at 37 weeks gestation presenting for a routine prenatal visit. appeared first on Study Bloom.