General Data: General Data IC , 2 7 y/o, married for 1 year G1P0, 39 2/7 weeks AOG, labor pains .
Past Medical History: Past Medical History (-) HTN (-) DM (-) BA (-) previous surgeries (-) allergies
Family History: Family History (+) HTN – maternal side (-) DM (-) BA (-) CA
Personal/Social History: Personal/Social History Housewife, Married x 1 year No vices
Menstrual History: Menstrual History Menarche at 12 y/o, RMI, 6 days duration, 2-3 moderately-soaked ppd, (+) dysmenorrhea
OB History: OB History G1 - present pregnancy
Review of Systems: Review of Systems (-) headache (-) dizziness
History of Present Illness: History of Present Illness
Physical Examination: Physical Examination Ambulatory, coherent, not distress BP = CR= /min RR= min Temp= C EENT = pinkish conjuctivae, (-) SCLA Breast = no masses Chest & Lungs: SCE, CBS, (-) wheeze/rales, adynamic precordium, NRRR, (-)murmur
Physical Examination: Physical Examination Abdomen = globular,NABS, (+) fluid wave, nontender (+) moderate- strong con tractions 4-5 mins Pelvic exam= NEG, non-parous vagina, Cx smooth, Extremities= grossly normal, (+) bipedal nonpitting edema grade 1
For the Alloimmunized Patient: For the Alloimmunized Patient See flowchart Indication for high-risk OB, or MFM specialist referral
Sources: Sources American College of Obstetricians and Gynecologists (ACOG). Prevention of Rh D alloimmunization. Washington (DC): American College of Obstetricians and Gynecologists (ACOG); 1999 May. 8 p. (ACOG practice bulletin; no. 4). Hemolytic disease of the newborn. dynaweb.ebscohost.com. Moise Jr., Kenneth. Pathogenesis and prenatal diagnosis of Rhesus (Rh) alloimmunization. www.uptodate.com . U.S. Preventive Services Task Force (USPSTF). Screening for Rh(D) incompatibility: recommendation statement. Rockville (MD): Agency for Healthcare Research and Quality (AHRQ); 2004 Feb. 4 p.