Assignment Prompt & Instructions
– 2 years ago
**files (1)**
– ## NRNP6552week9cases.pdf
**## NRNP6552week9cases.pdf**
Case #1. Teresa.
History of Present Illness (HPI): Teresa is a 34-year-old Hispanic G2P2002. She presents to your office
today at 10-weeks post-partum (PP) for her 6-week PP check. She underwent a C-section for failure to
progress following a 20-hour labor with Pitocin augmentation. She was discharged from the hospital on
day 2 post-partum without complications. Teresa has had difficulty with breast feeding due to
discomfort in her suture line and terrible pain in her right breast since her discharge from the hospital.
She reports occasional chills- she has not measured her temperature at home. Teresa was seen by the
lactation consultant while in the hospital but “nothing is working” and her son “cries all the time”. She
is afraid to feed her son formula as her mother-in-law wants her to “keep trying to breastfeed”. Teresa
tells you she feels as if she has failed her son- “it was so easy with my first baby, I know my husband
thinks I am a bad mother”.
Prior medical history: None. Prior surgical history: Appendectomy (2000)
Current medications: Prenatal vitamins, stool softener. Allergies: None
OB- GYN History: NSVD (2019) healthy female 7lb 10oz; C-section healthy male 8 lbs. 8 oz as per HPI.
Menarche age 12, cycle length- 5 days- frequency every 28 days- 4-5 tampons per day. No history of
sexually transmitted infections (STDs). History of abnormal pap smear in 2019 which was followed by a
normal colposcopy. Last pap (during recent prenatal care) reported normal. HIV negative.
LMP: First PP menstrual cycle last week. Has not resumed sexual activity PP. Contraception history:
Oral contraceptives, condoms.
Social history: Lives with husband, mother- in- law, and children. Stay at home mom. Denies EtOH or
recreational drug use, never smoker. Her family speaks Spanish at home; she is fluent in English.
Family history: Unremarkable.
Review of Systems (ROS): Negative except as noted in HPI.
Physical Exam (PE)
VS: BP: 110/70, P: 90, RR: 18, T: 38.4, Weight: 132 lbs.
Teresa’s C-section suture line is healing well without erythema or tenderness. No vaginal discharge or
lesions, no cervical motion tenderness (CMT), uterus normal size firm and non-tender. On breast exam,
you do note an erythematous, swollen, and painful area to the right breast. Her physical exam is
otherwise unremarkable.
Case #2. Joanna.
History of Present Illness (HPI): Joanna is a 28-year-old Caucasian G4P1021. She is single, living with her
father and 2-year-old daughter. She has a part-time job as a server at the local restaurant; she does not
have health insurance. Joanna presents to your office at the community health center today stating she
is pregnant and wants to receive OB care. She tells you that she has not yet been evaluated for this
pregnancy as she was afraid to take time off from work and did not have enough money to pay for the
visit.
Prior medical history: None. Prior surgical history: None
Current medications: None. Allergies: Penicillin
OB- GYN History: NSVD (2021) healthy female 6lb 8oz. Menarche age 10, cycle length- 3 days- irregular
cycles since menarche- frequency every 20-30 days- 2-3 tampons per day. No history of sexually
transmitted infections (STDs). Joanna’s OB history includes two first trimester elective terminations of
pregnancy, and 1 term female infant delivered vaginally at 37 weeks. Denies any complications during
her prior pregnancy however, she notes that her daughter experienced hypoglycemia and respiratory
distress, spending 2 weeks in the Neonatal Intensive Care Unit (NICU).
LMP: Approximately 5 months ago. Contraception history: Condoms “sometimes”.
Social history: Lives with her retired father and daughter. Restaurant server. Denies EtOH or
recreational drug use. Currently smoking 1 pack of cigarettes/ day (15 pack-year history). She and her
mother are still paying for her daughter’s NICU stay. The child’s father is not involved in any way.
Family history: Mother (deceased age 55)- Type 2 diabetes.
Review of Systems (ROS): Unremarkable with exception of dysuria (“it burns when I pee”) over the past
1-week. Denies fever, chills, abdominal or flank pain. Thick white vaginal discharge and “itching” for the
past month.
Physical Exam (PE)
VS: BP: 108/68, P: 72, RR: 18, T: 37.3, Weight 144lbs
On physical exam you palpate a fundal height of approximately 20cm with an audible fetal heart tone
(FHT) of 160. On speculum exam you visualize a multiparous cervix without lesions; bluish discoloration
of the cervix, vagina, and vulva is noted with a thick, white discharge. There is no cervical motion
tenderness (CMT) on exam. The uterus is anteverted, non- tender, with fundus palpable at the
umbilicus. Joanna’s physical exam is otherwise unremarkable.
Wet mount reveals budding yeast. Urine dipstick with 1+ leukocytes, trace blood and 2+ glucose.
Case #3. Monica.
History of Present Illness (HPI): Monica is a 43-year-old African- American G3P2102. She is currently
separated from her husband of 20 years and is working full-time as a legal secretary. About 8 months
ago, Monica started having irregular periods with heavier than usual flow until she stopped having
periods or any vaginal bleeding about 3 months ago. She is currently recovering from a “stomach flu”
however, she reports daily nausea, vomiting, bloating and decreased appetite over the past 3 weeks.
She is worried because she has gained 12 pounds over the last 3 months “due to menopause”. She
comes to the clinic today to discuss menopause symptoms and hormone replacement therapy.
Prior medical history: Hypertension (2010)- well controlled on current antihypertensive
Prior surgical history: Cholecystectomy (2015)
Current medications: Lisinopril 10mg daily. Allergies: None
OB- GYN History: NSVD x 2 (2015, 2019) healthy female 6lb 8oz; healthy female 7lbs 6oz. First trimester
miscarriage (9 weeks) in 2014. Menarche age 15, cycle length-7 days- frequency every 28 days- 5-6 pads
per day. No history of sexually transmitted infections (STDs). No history of abnormal pap (last pap 2
years ago).
LMP: Approximately 3 months ago. Contraception history: Condoms; past use of oral contraceptives.
Social history: Lives with her elderly father, 2 daughters. Separated from her husband for 6 months.
Family history: Mother deceased (age 60)- breast cancer. Father alive (age 70)- hypertension.
Review of Systems (ROS): Unremarkable with exception of as noted in HPI.
Physical Exam (PE)
VS: BP: 130/78, P: 78, RR: 18, T: 36.1 Weight: 152 lbs.
Physical exam is unremarkable with exception of a palpable 12- 14 weeks size uterus on bimanual. You
check a for a fetal heartbeat and obtain a heart tone of 145 via doppler. The intake nurse reports that a
urine pregnancy test came back positive.
Monica is in disbelief.
Case #4. Laura.
History of Present Illness (HPI): Laura is a 16-year-old Caucasian G1P0. She presents to your office after
missing her second period. She is “worried” as she “always gets her period on time”. She is in high
school- about to enter the 11th grade. She lives with her grandmother and 2 older siblings. Her urine
pregnancy test in clinic today is positive.
Laura is sexually active with her boyfriend; they do not use condoms. He “pulls out” as birth control.
She reports being treated at the health department for chlamydia and gonorrhea earlier this year. She
thinks her boyfriend was treated but he is not answering her calls since she told him about the missed
periods a few weeks ago. She reports daily nausea, vomiting and dysuria for the past 2 weeks.
Prior medical history: None. Prior surgical history: None
Current medications: None. Allergies: None
OB- GYN History: Menarche age 12, cycle length-7 days- frequency every 30 days- 2 tampons per day.
History of chlamydia and gonorrhea (GC) in the past year. Last pap reported normal at the time of
chlamydia/ GC diagnosis. Has not received Human Papillomavirus (HPV) vaccine.
LMP: Approximately 2 months ago. Contraception history: Withdrawal
Social history: Lives with her grandmother, siblings. Denies EtOH or recreational drug use. Currently
smoking 1 pack of cigarettes/ day
Family history: Mother deceased at age 42- drug overdose. Father unknown.
Review of Systems (ROS): Unremarkable with exception of as noted in HPI.
Physical Exam (PE)
VS: BP: 110/68, P: 80, RR: 18, T: 37.1 Weight: 110 lbs. (states usual weight 120 lbs.).
Physical exam is unremarkable with exception of a cloudy, yellow mucoid cervical discharge on speculum
exam; friable appearance of the cervix with cervical motion tenderness (CMT). You palpate an 8-week
size uterus on bimanual.
Laura’s urine reveals 2+ ketones, 2+ nitrates, and 3+ leukocytes.
Case 5: Denise.
Denise is a 30-year-old Black female G0 with a history of seizure disorder who presents to clinic for her
annual well visit. She is excited to tell you that she is getting married in 2 months and they are planning
to start a family “right away”. Denise went to see her gynecologist last month who told her she was
“young and healthy- not to worry, everything will work out fine”. No labs were done at the gyn visit; she
hasn’t started prenatal vitamins. She comes to see you today as she “wants to be sure that she is up to
date on everything she needs” before the wedding.
Prior medical history: Seizure disorder (diagnosed at age 18). Prior surgical history: None
Current medications: Levetiracetam 500mg 2 times a day. Allergies: None
Reports she believes she has had all childhood vaccinations. Has not received COVID or influenza
vaccines. She is not sure about Hepatitis B or Tdap.
OB- GYN History: G0. Menarche age 14, cycle length-5 days- frequency every 28 days- 2-3 pads per day.
No history of sexually transmitted infection. Last PAP 2020, no history of abnormal PAP. Has not
received Human Papillomavirus (HPV) vaccine. Her only sexual partner is her current fiancé (male). LMP
was approximately 2 weeks ago. Contraception history: Condoms.
Social history: Sixth grade teacher. Lives with her fiancé. Denies EtOH or recreational drug use. Has
never smoked cigarettes or vaped.
Family history: Mother (age 56) alive and well. Father deceased at age 50 from lung cancer (smoker).
Sister aged 21- healthy. Maternal grandmother alive age 88 (hysterectomy for fibroid uterus). Maternal
grandfather deceased age 78 (unknown cause). Paternal grandparents- unknown.
Review of Systems (ROS).
Constitutional: No Weight Change, No Fever, No Chills, No Night Sweats, No Fatigue, No Malaise
ENT/Mouth: No Hearing Changes, No Ear Pain, No Nasal Congestion, No Sinus Pain, No Hoarseness, No
sore throat, No Rhinorrhea, No Swallowing Difficulty
Eyes: No Eye Pain, No Swelling, No Redness, No Foreign Body, No Discharge, No Vision Changes
Cardiovascular: No Chest Pain, No SOB, No Dyspnea on Exertion, No Orthopnea, No Claudication, No
Edema, No Palpitations
Respiratory: No Cough, No Sputum, No Wheezing, No Smoke Exposure, No Dyspnea
Gastrointestinal: No Nausea, No Vomiting, No Diarrhea, Occasional Constipation (managed with diet),
No Pain, No Heartburn, No Anorexia, No Dysphagia, No Hematochezia, No Melena, No Flatulence, No
Jaundice
Genitourinary: No Dysmenorrhea, No Abnormal Vaginal Bleeding, No Dyspareunia, No Dysuria, No
Urinary Frequency, No Hematuria, No Urinary Incontinence, No Urgency, No Flank Pain, No Urinary Flow
Changes, No Hesitancy
Musculoskeletal: No Arthralgias, No Myalgias, No Joint Swelling, No Joint Stiffness, No Back Pain, No
Neck Pain, No Injury History
Skin: No Skin Lesions, No Pruritis, No Hair Changes, No Breast/Skin Changes, No Nipple Discharge
Neuro: No Weakness, No Numbness, No Paresthesia, No Loss of Consciousness, No Syncope, No
Dizziness, No Headache, No Coordination Changes. Last reported seizure was 10 years ago. Followed by
neurologist- last seen in 2023.
Psych: No Anxiety/Panic, No Depression, No Insomnia. No Memory Changes. Denies Violence/Abuse,
No Eating Concerns
Heme/Lymph: No Bruising, No Bleeding, No Transfusion History, No Lymphadenopathy
Endocrine: No Polyuria, No Polydipsia, No Temperature Intolerance
Physical Exam (PE).
VS: BP: 130/84, P: 80, RR: 18, T: 37.1, Weight: 118 lbs. BMI 19.0
General: Awake, alert, and oriented. No acute distress. Well developed, hydrated, and nourished.
Appears stated age.
Skin: Skin in warm, dry, and intact without rashes or lesions. Appropriate color for ethnicity. Nailbeds
pink with no cyanosis or clubbing.
Head: The head is normocephalic and atraumatic without tenderness, visible or palpable masses,
depressions, or scarring. Hair is of normal texture and evenly distributed.
Eyes: Conjunctivae are clear without exudates or hemorrhage. Sclera is non-icteric. No signs of
nystagmus. Eyelids are normal in appearance without swelling or lesions.
Ears: The external ear and ear canal are non-tender and without swelling.
Nose: Nasal mucosa is pink and moist. Nares are patent bilaterally.
Throat: Oral mucosa is pink and moist with good dentition. Tongue normal in appearance without lesions
and with good symmetrical movement. The pharynx is normal in appearance without tonsillar swelling
or exudates.
Neck: The neck is supple without adenopathy. Trachea is midline. Thyroid gland is normal without
masses.
Cardiac: The external chest is normal in appearance. Heart rate and rhythm are normal. No murmurs,
gallops, or rubs are auscultated.
Respiratory: The chest wall is symmetric and without deformity. Lung sounds are clear in all lobes
bilaterally without rales, rhonchi, or wheezes.
Breasts: Symmetrical. No Masses, Dimpling or Nipple Discharge. No Axillary Adenopathy.
Abdominal: Abdomen is soft, symmetric, and non-tender without distention. There are no visible lesions
or scars. Umbilicus is midline without herniation. Bowel sounds are present and normoactive in all four
quadrants. No masses, hepatomegaly, or splenomegaly are noted.
Genital: External genitalia is normal in appearance without lesions, swelling, masses or tenderness.
Vagina is pink and moist without lesions or discharge. Cervix is non-tender without lesions. Uterus is
anteflexed, non-tender and normal in size. Ovaries are non-tender without palpable masses or
enlargement.
Extremities: Upper and lower extremities are atraumatic in appearance without tenderness or deformity.
No swelling or erythema.
Neurological: The patient is awake, alert, and oriented to person, place, and time with normal speech.
Motor function is normal with muscle strength 5/5 bilaterally to upper and lower extremities. Sensation
is intact bilaterally. Reflexes 2+ bilaterally. No gait abnormalities are appreciated.
Psychiatric: Appropriate mood and affect. Good judgement and insight. No suicidal or homicidal
ideation.
What is your pre conceptual plan for Denise? What are her risks?
Keep in mind that the goal of pre-conceptual care is to reduce the risk of adverse health effects for the
woman, fetus, and neonate- optimize health and prevention; address modifiable risk factors, chronic
illnesses, and medication safety.
**## NRNP6552week9cases.pdf**
Case #1. Teresa.
History of Present Illness (HPI): Teresa is a 34-year-old Hispanic G2P2002. She presents to your office
today at 10-weeks post-partum (PP) for her 6-week PP check. She underwent a C-section for failure to
progress following a 20-hour labor with Pitocin augmentation. She was discharged from the hospital on
day 2 post-partum without complications. Teresa has had difficulty with breast feeding due to
discomfort in her suture line and terrible pain in her right breast since her discharge from the hospital.
She reports occasional chills- she has not measured her temperature at home. Teresa was seen by the
lactation consultant while in the hospital but “nothing is working” and her son “cries all the time”. She
is afraid to feed her son formula as her mother-in-law wants her to “keep trying to breastfeed”. Teresa
tells you she feels as if she has failed her son- “it was so easy with my first baby, I know my husband
thinks I am a bad mother”.
Prior medical history: None. Prior surgical history: Appendectomy (2000)
Current medications: Prenatal vitamins, stool softener. Allergies: None
OB- GYN History: NSVD (2019) healthy female 7lb 10oz; C-section healthy male 8 lbs. 8 oz as per HPI.
Menarche age 12, cycle length- 5 days- frequency every 28 days- 4-5 tampons per day. No history of
sexually transmitted infections (STDs). History of abnormal pap smear in 2019 which was followed by a
normal colposcopy. Last pap (during recent prenatal care) reported normal. HIV negative.
LMP: First PP menstrual cycle last week. Has not resumed sexual activity PP. Contraception history:
Oral contraceptives, condoms.
Social history: Lives with husband, mother- in- law, and children. Stay at home mom. Denies EtOH or
recreational drug use, never smoker. Her family speaks Spanish at home; she is fluent in English.
Family history: Unremarkable.
Review of Systems (ROS): Negative except as noted in HPI.
Physical Exam (PE)
VS: BP: 110/70, P: 90, RR: 18, T: 38.4, Weight: 132 lbs.
Teresa’s C-section suture line is healing well without erythema or tenderness. No vaginal discharge or
lesions, no cervical motion tenderness (CMT), uterus normal size firm and non-tender. On breast exam,
you do note an erythematous, swollen, and painful area to the right breast. Her physical exam is
otherwise unremarkable.
Case #2. Joanna.
History of Present Illness (HPI): Joanna is a 28-year-old Caucasian G4P1021. She is single, living with her
father and 2-year-old daughter. She has a part-time job as a server at the local restaurant; she does not
have health insurance. Joanna presents to your office at the community health center today stating she
is pregnant and wants to receive OB care. She tells you that she has not yet been evaluated for this
pregnancy as she was afraid to take time off from work and did not have enough money to pay for the
visit.
Prior medical history: None. Prior surgical history: None
Current medications: None. Allergies: Penicillin
OB- GYN History: NSVD (2021) healthy female 6lb 8oz. Menarche age 10, cycle length- 3 days- irregular
cycles since menarche- frequency every 20-30 days- 2-3 tampons per day. No history of sexually
transmitted infections (STDs). Joanna’s OB history includes two first trimester elective terminations of
pregnancy, and 1 term female infant delivered vaginally at 37 weeks. Denies any complications during
her prior pregnancy however, she notes that her daughter experienced hypoglycemia and respiratory
distress, spending 2 weeks in the Neonatal Intensive Care Unit (NICU).
LMP: Approximately 5 months ago. Contraception history: Condoms “sometimes”.
Social history: Lives with her retired father and daughter. Restaurant server. Denies EtOH or
recreational drug use. Currently smoking 1 pack of cigarettes/ day (15 pack-year history). She and her
mother are still paying for her daughter’s NICU stay. The child’s father is not involved in any way.
Family history: Mother (deceased age 55)- Type 2 diabetes.
Review of Systems (ROS): Unremarkable with exception of dysuria (“it burns when I pee”) over the past
1-week. Denies fever, chills, abdominal or flank pain. Thick white vaginal discharge and “itching” for the
past month.
Physical Exam (PE)
VS: BP: 108/68, P: 72, RR: 18, T: 37.3, Weight 144lbs
On physical exam you palpate a fundal height of approximately 20cm with an audible fetal heart tone
(FHT) of 160. On speculum exam you visualize a multiparous cervix without lesions; bluish discoloration
of the cervix, vagina, and vulva is noted with a thick, white discharge. There is no cervical motion
tenderness (CMT) on exam. The uterus is anteverted, non- tender, with fundus palpable at the
umbilicus. Joanna’s physical exam is otherwise unremarkable.
Wet mount reveals budding yeast. Urine dipstick with 1+ leukocytes, trace blood and 2+ glucose.
Case #3. Monica.
History of Present Illness (HPI): Monica is a 43-year-old African- American G3P2102. She is currently
separated from her husband of 20 years and is working full-time as a legal secretary. About 8 months
ago, Monica started having irregular periods with heavier than usual flow until she stopped having
periods or any vaginal bleeding about 3 months ago. She is currently recovering from a “stomach flu”
however, she reports daily nausea, vomiting, bloating and decreased appetite over the past 3 weeks.
She is worried because she has gained 12 pounds over the last 3 months “due to menopause”. She
comes to the clinic today to discuss menopause symptoms and hormone replacement therapy.
Prior medical history: Hypertension (2010)- well controlled on current antihypertensive
Prior surgical history: Cholecystectomy (2015)
Current medications: Lisinopril 10mg daily. Allergies: None
OB- GYN History: NSVD x 2 (2015, 2019) healthy female 6lb 8oz; healthy female 7lbs 6oz. First trimester
miscarriage (9 weeks) in 2014. Menarche age 15, cycle length-7 days- frequency every 28 days- 5-6 pads
per day. No history of sexually transmitted infections (STDs). No history of abnormal pap (last pap 2
years ago).
LMP: Approximately 3 months ago. Contraception history: Condoms; past use of oral contraceptives.
Social history: Lives with her elderly father, 2 daughters. Separated from her husband for 6 months.
Family history: Mother deceased (age 60)- breast cancer. Father alive (age 70)- hypertension.
Review of Systems (ROS): Unremarkable with exception of as noted in HPI.
Physical Exam (PE)
VS: BP: 130/78, P: 78, RR: 18, T: 36.1 Weight: 152 lbs.
Physical exam is unremarkable with exception of a palpable 12- 14 weeks size uterus on bimanual. You
check a for a fetal heartbeat and obtain a heart tone of 145 via doppler. The intake nurse reports that a
urine pregnancy test came back positive.
Monica is in disbelief.
Case #4. Laura.
History of Present Illness (HPI): Laura is a 16-year-old Caucasian G1P0. She presents to your office after
missing her second period. She is “worried” as she “always gets her period on time”. She is in high
school- about to enter the 11th grade. She lives with her grandmother and 2 older siblings. Her urine
pregnancy test in clinic today is positive.
Laura is sexually active with her boyfriend; they do not use condoms. He “pulls out” as birth control.
She reports being treated at the health department for chlamydia and gonorrhea earlier this year. She
thinks her boyfriend was treated but he is not answering her calls since she told him about the missed
periods a few weeks ago. She reports daily nausea, vomiting and dysuria for the past 2 weeks.
Prior medical history: None. Prior surgical history: None
Current medications: None. Allergies: None
OB- GYN History: Menarche age 12, cycle length-7 days- frequency every 30 days- 2 tampons per day.
History of chlamydia and gonorrhea (GC) in the past year. Last pap reported normal at the time of
chlamydia/ GC diagnosis. Has not received Human Papillomavirus (HPV) vaccine.
LMP: Approximately 2 months ago. Contraception history: Withdrawal
Social history: Lives with her grandmother, siblings. Denies EtOH or recreational drug use. Currently
smoking 1 pack of cigarettes/ day
Family history: Mother deceased at age 42- drug overdose. Father unknown.
Review of Systems (ROS): Unremarkable with exception of as noted in HPI.
Physical Exam (PE)
VS: BP: 110/68, P: 80, RR: 18, T: 37.1 Weight: 110 lbs. (states usual weight 120 lbs.).
Physical exam is unremarkable with exception of a cloudy, yellow mucoid cervical discharge on speculum
exam; friable appearance of the cervix with cervical motion tenderness (CMT). You palpate an 8-week
size uterus on bimanual.
Laura’s urine reveals 2+ ketones, 2+ nitrates, and 3+ leukocytes.
Case 5: Denise.
Denise is a 30-year-old Black female G0 with a history of seizure disorder who presents to clinic for her
annual well visit. She is excited to tell you that she is getting married in 2 months and they are planning
to start a family “right away”. Denise went to see her gynecologist last month who told her she was
“young and healthy- not to worry, everything will work out fine”. No labs were done at the gyn visit; she
hasn’t started prenatal vitamins. She comes to see you today as she “wants to be sure that she is up to
date on everything she needs” before the wedding.
Prior medical history: Seizure disorder (diagnosed at age 18). Prior surgical history: None
Current medications: Levetiracetam 500mg 2 times a day. Allergies: None
Reports she believes she has had all childhood vaccinations. Has not received COVID or influenza
vaccines. She is not sure about Hepatitis B or Tdap.
OB- GYN History: G0. Menarche age 14, cycle length-5 days- frequency every 28 days- 2-3 pads per day.
No history of sexually transmitted infection. Last PAP 2020, no history of abnormal PAP. Has not
received Human Papillomavirus (HPV) vaccine. Her only sexual partner is her current fiancé (male). LMP
was approximately 2 weeks ago. Contraception history: Condoms.
Social history: Sixth grade teacher. Lives with her fiancé. Denies EtOH or recreational drug use. Has
never smoked cigarettes or vaped.
Family history: Mother (age 56) alive and well. Father deceased at age 50 from lung cancer (smoker).
Sister aged 21- healthy. Maternal grandmother alive age 88 (hysterectomy for fibroid uterus). Maternal
grandfather deceased age 78 (unknown cause). Paternal grandparents- unknown.
Review of Systems (ROS).
Constitutional: No Weight Change, No Fever, No Chills, No Night Sweats, No Fatigue, No Malaise
ENT/Mouth: No Hearing Changes, No Ear Pain, No Nasal Congestion, No Sinus Pain, No Hoarseness, No
sore throat, No Rhinorrhea, No Swallowing Difficulty
Eyes: No Eye Pain, No Swelling, No Redness, No Foreign Body, No Discharge, No Vision Changes
Cardiovascular: No Chest Pain, No SOB, No Dyspnea on Exertion, No Orthopnea, No Claudication, No
Edema, No Palpitations
Respiratory: No Cough, No Sputum, No Wheezing, No Smoke Exposure, No Dyspnea
Gastrointestinal: No Nausea, No Vomiting, No Diarrhea, Occasional Constipation (managed with diet),
No Pain, No Heartburn, No Anorexia, No Dysphagia, No Hematochezia, No Melena, No Flatulence, No
Jaundice
Genitourinary: No Dysmenorrhea, No Abnormal Vaginal Bleeding, No Dyspareunia, No Dysuria, No
Urinary Frequency, No Hematuria, No Urinary Incontinence, No Urgency, No Flank Pain, No Urinary Flow
Changes, No Hesitancy
Musculoskeletal: No Arthralgias, No Myalgias, No Joint Swelling, No Joint Stiffness, No Back Pain, No
Neck Pain, No Injury History
Skin: No Skin Lesions, No Pruritis, No Hair Changes, No Breast/Skin Changes, No Nipple Discharge
Neuro: No Weakness, No Numbness, No Paresthesia, No Loss of Consciousness, No Syncope, No
Dizziness, No Headache, No Coordination Changes. Last reported seizure was 10 years ago. Followed by
neurologist- last seen in 2023.
Psych: No Anxiety/Panic, No Depression, No Insomnia. No Memory Changes. Denies Violence/Abuse,
No Eating Concerns
Heme/Lymph: No Bruising, No Bleeding, No Transfusion History, No Lymphadenopathy
Endocrine: No Polyuria, No Polydipsia, No Temperature Intolerance
Physical Exam (PE).
VS: BP: 130/84, P: 80, RR: 18, T: 37.1, Weight: 118 lbs. BMI 19.0
General: Awake, alert, and oriented. No acute distress. Well developed, hydrated, and nourished.
Appears stated age.
Skin: Skin in warm, dry, and intact without rashes or lesions. Appropriate color for ethnicity. Nailbeds
pink with no cyanosis or clubbing.
Head: The head is normocephalic and atraumatic without tenderness, visible or palpable masses,
depressions, or scarring. Hair is of normal texture and evenly distributed.
Eyes: Conjunctivae are clear without exudates or hemorrhage. Sclera is non-icteric. No signs of
nystagmus. Eyelids are normal in appearance without swelling or lesions.
Ears: The external ear and ear canal are non-tender and without swelling.
Nose: Nasal mucosa is pink and moist. Nares are patent bilaterally.
Throat: Oral mucosa is pink and moist with good dentition. Tongue normal in appearance without lesions
and with good symmetrical movement. The pharynx is normal in appearance without tonsillar swelling
or exudates.
Neck: The neck is supple without adenopathy. Trachea is midline. Thyroid gland is normal without
masses.
Cardiac: The external chest is normal in appearance. Heart rate and rhythm are normal. No murmurs,
gallops, or rubs are auscultated.
Respiratory: The chest wall is symmetric and without deformity. Lung sounds are clear in all lobes
bilaterally without rales, rhonchi, or wheezes.
Breasts: Symmetrical. No Masses, Dimpling or Nipple Discharge. No Axillary Adenopathy.
Abdominal: Abdomen is soft, symmetric, and non-tender without distention. There are no visible lesions
or scars. Umbilicus is midline without herniation. Bowel sounds are present and normoactive in all four
quadrants. No masses, hepatomegaly, or splenomegaly are noted.
Genital: External genitalia is normal in appearance without lesions, swelling, masses or tenderness.
Vagina is pink and moist without lesions or discharge. Cervix is non-tender without lesions. Uterus is
anteflexed, non-tender and normal in size. Ovaries are non-tender without palpable masses or
enlargement.
Extremities: Upper and lower extremities are atraumatic in appearance without tenderness or deformity.
No swelling or erythema.
Neurological: The patient is awake, alert, and oriented to person, place, and time with normal speech.
Motor function is normal with muscle strength 5/5 bilaterally to upper and lower extremities. Sensation
is intact bilaterally. Reflexes 2+ bilaterally. No gait abnormalities are appreciated.
Psychiatric: Appropriate mood and affect. Good judgement and insight. No suicidal or homicidal
ideation.
What is your pre conceptual plan for Denise? What are her risks?
Keep in mind that the goal of pre-conceptual care is to reduce the risk of adverse health effects for the
woman, fetus, and neonate- optimize health and prevention; address modifiable risk factors, chronic
illnesses, and medication safety.