Physical assessment database

Topics: Childbirth, Pregnancy, Cervix Pages: 6 (1750 words) Published: November 11, 2013
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 anxious at this time related to fear of the unknown related to PTL. Family History:
MGF- congestive heart failure, diabetes, passed away age 79
MGM- restrictive lung disease (previous smoker), passed away age 78
PGF- prostate cancer in remission, “abdominal cancer” in remission
PGM- depression, HTN, ovarian cancer (TAH)
Father- passed away age 58 of MI, history HTN, hypercholesteremia
Mother- cervical cancer (TAH), depression
MD reports her children are healthy with no known illnesses or diseases Personal and Social History: MD was born in Mobile, AL and moved to Central LA at age 4. She attended Bolton High School and graduated in 1998. She then attended Pineville Beauty School where she earned a license in Cosmetology. She worked as a hair stylist until the birth of her first child and has since been a stay-at-home mother. Her husband works fulltime in construction. She does admit the strain of one income has been a concern in the past, but staying home with her children is important to both her and her husband. MD reports a supportive husband and extended family. Environmental: MD states her husband smokes 1 pack of cigarettes daily, outside of the home and never in vehicle while children are present. She states he does smoke in car with her. Current health habits: MD states she leads a moderately active lifestyle but admits to being out-of-shape. She denies illicit drug use. MD reports socially drinking occasionally, denies doing so during pregnancy. MD states family meals consist of seasonal vegetables as her husband’s family are avid gardeners. She states she wears sunscreen when planning to be outside for a significant amount of time. Exposure to chemicals or toxins: MD states her past as a hair stylists consisted of exposure to chemicals when dyeing hair. She reports using gloves at that time. She denies any exposure to chemicals or toxins in her daily life at this time. Sexual activity: MD denies any past history of STD’s.

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