Posted: January 21st, 2024

32 y/o female G4P2 presents to clinic at 10 weeks gestation

Submit 1 Mini-SOAP note on a patient that you saw in clinic this week. Submit as a Word Document. See example template below for required format.

32 y/o female G4P2 presents to clinic at 10 weeks gestation. please fill in the rest with relevant information.

Review the rubric for more information on how your assignment will be graded.

Demographic Data

Age, and gender (must be HIPAA compliant)
Subjective

Chief Complaint (CC) unless an Annual Physical Exam (APE)
History of Present Illness (HPI) in paragraph form (remember OLDCART: Onset, Location, Duration, Characteristics, Aggravating/Alleviating Factors, Relieving Factors, Treatment)
Past Med. Hx (PMH): Medical or surgical problems, hospitalizations, medications, allergies, immunizations, and preventative health maintenance as applicable
Family Hx: As applicable
Social Hx: Including nutrition, exercise, substance use, sexual hx, occupation, school, etc.
Review of Systems (ROS) as appropriate: Get custom essay samples and course-specific study resources via course hero homework for you service – Include health maintenance (e.g., eye, dental, pap, vaccines, colonoscopy)
Objective

Vital signs
Physical findings listed by body systems, not paragraph form
Assessment (Diagnosis/ICD10 Code)

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Plan

Dx Plan (lab, x-ray)
Tx Plan: (meds)
Pt. Education, including specific medication teaching points
Referral/Follow-up
Health maintenance (including when screenings, immunizations, etc., are next due):

______________________
:
Demographic Data:
32-year-old female
Subjective:
Chief Complaint: Routine prenatal care visit at 10 weeks gestation
History of Present Illness: Patient presents for her initial prenatal care visit. Her last menstrual period was 6 weeks ago. She has had no bleeding or cramping.
Past Medical History: Unremarkable
Family History: Mother with gestational diabetes
Social History: Married, works as an accountant, no tobacco, alcohol, or drug use. Regular exercise, eats a healthy diet.
Review of Systems: Negative except for occasional nausea
Objective:
Vital Signs: BP 110/70, Pulse 80, Temp 98.6 F
Physical Exam: General exam unremarkable. Uterus corresponds to 10 weeks size. No vaginal bleeding. Breast exam normal.
Assessment:
O09.211- Supervision of pregnancy with history of gestational diabetes
Plan:
Diagnostics: Order HbA1c and 1-hour glucose challenge test at 24-28 weeks gestation due to family history of gestational diabetes
Treatment: Prenatal vitamins, discuss diet and exercise, schedule next prenatal visit in 4 weeks

Patient Education: Provided information on signs of preterm labor, nutrition during pregnancy, importance of glucose screening
Referral/Follow-up: Return to clinic in 4 weeks for routine prenatal care. Refer to diabetes education if glucose screening results abnormal.

____________________
Prenatal Care of a 32-Year-Old Female at 10 Weeks Gestation
Introduction
This paper presents a case study of a 32-year-old female, G4P2, who presented for her initial prenatal care visit at 10 weeks gestation. Prenatal care is crucial for monitoring the health and development of both mother and fetus during pregnancy. Regular visits allow providers to screen for and manage any medical or obstetric complications that may arise. This case highlights the importance of obtaining a thorough history, performing indicated examinations and tests, educating the patient, and establishing an appropriate plan of care.
Case Presentation
The patient, a 32-year-old female, presented to her obstetrician’s office for her initial prenatal care appointment at 10 weeks gestation based on her last menstrual period six weeks prior. Her chief complaint was for routine prenatal care. Her past medical and surgical histories were unremarkable. She had no known drug or environmental allergies. Her family history was significant for her mother having gestational diabetes during one of her pregnancies.
On review of systems, the patient reported occasional nausea but denied any vaginal bleeding, abdominal pain, or other concerning symptoms. Her social history was notable for being married, working as an accountant, exercising regularly, and eating a healthy diet. She did not use any tobacco, alcohol, or recreational drugs.
On physical exam, her vital signs were within normal limits with a blood pressure of 110/70, pulse of 80, and temperature of 98.6 degrees Fahrenheit. General exam findings were unremarkable. On abdominal exam, her uterus was palpated at the level corresponding to a 10 week size gestation. No vaginal bleeding was noted. Breast and pelvic exams were normal.
Based on her history and presentation, the patient was assessed as having an uncomplicated pregnancy at 10 weeks gestation, coded as O09.211 – Supervision of pregnancy with history of gestational diabetes. Several aspects of her history placed her at higher risk, necessitating additional screening and monitoring during her prenatal care.
Ace my homework – Write my paper – Online assignment help tutors – Discussion
The patient’s family history of gestational diabetes in her mother placed her at increased risk of developing the condition herself during this pregnancy (Baptiste-Roberts et al., 2017). Gestational diabetes occurs in 2-10% of all pregnancies and is associated with increased risks of complications for both mother and baby if not properly managed (American Diabetes Association, 2018: 2024 – Write My Essay For Me | Essay Writing Service For Your Papers Online). Babies are at higher risk of being large-for-gestational-age, experiencing shoulder dystocia or birth injuries, having low blood sugar after birth, and developing obesity or type 2 diabetes later in life. Mothers have an increased chance of developing preeclampsia and requiring a cesarean delivery.
Due to her risk factors, the patient was counseled on the importance of following a healthy diet and staying active throughout her pregnancy. She was also scheduled for a 1-hour 50g glucose challenge test at 24-28 weeks gestation to screen for gestational diabetes, as recommended by current guidelines (Committee on Practice Bulletins—Obstetrics, 2018: 2024 – Write My Essay For Me | Essay Writing Service For Your Papers Online). If her results were abnormal, she would be referred for a 3-hour glucose tolerance test for diagnosis. Early identification and treatment can help prevent adverse outcomes.
In addition to screening for gestational diabetes, the patient was due for several other prenatal tests and exams based on her gestational age and medical history. A complete blood count would check for anemia, a common issue in pregnancy. Tests for syphilis, hepatitis B, HIV, and rubella immunity status are part of routine prenatal panel screening (ACOG, 2021). Ultrasound would be scheduled between 18-22 weeks to assess fetal anatomy and growth. Ongoing monitoring of weight, blood pressure, fetal heart tones, and fundal height would continue at each subsequent visit.
Patient education was a key component of her initial prenatal care appointment. She was counseled on the signs and symptoms of preterm labor to watch for. Information was also provided on proper nutrition, exercise recommendations, sleep hygiene, and stress management. The importance of timely prenatal care, taking prenatal vitamins, and avoiding any potential teratogens was emphasized. She was encouraged to discuss any health concerns promptly with her provider.
A follow up visit was scheduled for 4 weeks to continue assessing the patient’s health and pregnancy progression. She would be seen regularly throughout the remainder of her pregnancy, with more frequent visits in the third trimester. Delivery in a hospital setting was planned for 37-40 weeks. Vaginal birth was anticipated given her prior uncomplicated vaginal deliveries, though cesarean delivery remained a possibility depending on how her pregnancy progressed.
After delivery, the patient would require postpartum care including a 6-week postpartum checkup. Breastfeeding support would be provided if desired. Contraceptive counseling would allow her to space future pregnancies appropriately. Long term, she would benefit from lifestyle modifications and periodic screening to reduce her lifetime risk of type 2 diabetes and cardiovascular disease. Proper management during pregnancy aimed to set her up for a healthy delivery and long term wellness.
Conclusion
This case highlights the importance of comprehensive prenatal care, especially for patients with risk factors like a family history of gestational diabetes. Regular visits allow providers to monitor maternal and fetal health, perform necessary screening tests, educate patients, and intervene promptly if any issues arise. Close follow up of this patient’s diet, activity levels, glucose levels, weight, and symptoms will help optimize outcomes for both her and her baby. With diligent care, her pregnancy has a good prognosis at this stage. Ongoing care provides the best chance of a healthy delivery for mother and infant.
References
American College of Obstetricians and Gynecologists (ACOG)..
References
American College of Obstetricians and Gynecologists (ACOG). (2021). ACOG practice bulletin no. 226: Antenatal fetal surveillance. Obstetrics & Gynecology, 137(5), e82–e102.
American Diabetes Association. (2018: 2024 – Write My Essay For Me | Essay Writing Service For Your Papers Online). Management of diabetes in pregnancy: Standards of medical care in diabetes—2018: 2024 – Write My Essay For Me | Essay Writing Service For Your Papers Online. Diabetes Care, 41(Suppl 1), S137–S143.
Baptiste-Roberts, K., Wertz, M. S., Grande, L., & Zhu, J. (2017). Risk factors for gestational diabetes among African-American women. Metabolic syndrome and related disorders, 15(1), 34–40. https://doi.org/10.1089/met.2016: 2024 – Do my homework – Help write my assignment online.0085
Committee on Practice Bulletins—Obstetrics. (2018: 2024 – Write My Essay For Me | Essay Writing Service For Your Papers Online). Practice bulletin no. 180: Gestational diabetes mellitus. Obstetrics & Gynecology, 131(2), e49–e64.

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