History Physical Assessment Explained for Students (Easy Guide)
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Original Question
History and Physical Assessment Nurses’ Notes Vital Signs Laboratory Results Patient is diaphoretic and states she is nauseous and lightheaded. OMM (oral mucous membranes) are pale pink. DTRs are normal and no signs of clonus. Obstetric history: Patient is a 38-year-old White female, G8P6117 delivered precipitously Lungs are clear to auscultation in all fields, and bowel sounds are active in all at 38.4 weeks in OB triage at 1706. QBL was 750 mL. EDD was 7/01/XX based on LMP. four quadrants. Fundal height is 1 cm above umbilicus, boggy and midline, Patient was late to prenatal care, 22.1 weeks at first appointment, but compliant with care massaged with no change. Lochia is heavy. since. Patient has a history of GDM with her 3 most recent pregnancies, including this one. Temp 98.4 F (36.9.C) . First pregnancy 12 years ago: SVD at 40.1, 2nd degree laceration, 3,471 g viable HR 98 bpm; regular male. . Second pregnancy 10 years ago: SVD at 38.5, no complications, 3,682 g viable male. RR 22 breaths/min . Third pregnancy 8 years ago: SAB at 16 weeks. No significant pathology. Sp02 97% on room air . Fourth pregnancy 8 years ago: SVD 36.4 weeks. Induction of labor due to PPROM. IBP 98/54 mm Hg: 3,214 g viable female. Pain 2 on 1-10 scale, abdomen . Fifth pregnancy 6 years ago: 1- and 3-hour GTT high normal. Precipitous SVD at 38.1. 3,890 g viable male. Sivth nronnancy 5 veare ann. Induction of lahar due to culenacted marcomia and
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