Writing Up the Physical Examination

Listed here are examples of the write-up for the assessment of the pregnant patient.

• Patient is a 32-year-old white woman, para 2-0-0-2 (see Chapter 19, Female Genitalia). Her larger infant weighed 7 pounds 4 ounces. Both deliveries were normal, spontaneous, and vaginal. LMP = 8/1/08. EDC = 5/8/09. Blood pressure is 125/80. Findings of examination of the head, eye, ear, nose, throat, and neck are unremarkable except for presence of chloasma. Breasts are symmetrically enlarged with venous pattern visible. Colostrum expressed. Chest is clear to percussion and auscultation. Heart rate is 100 and regular.

Heart sounds are normal. A grade II/VI midsystolic murmur is heard at the aortic area. No gallops are present. Examination of the abdomen reveals a 32-week gestation and is appropriate for dates. There are reddish, slightly depressed streaks on the lower abdomen. 1+ pretibial edema is present bilaterally. Movement of the fetus is felt. The fetus is in a longitudinal lie in a vertex presentation, with its back to the left. Fetal heart rate is 150 and is heard through the back of the fetus, 2 cm to the left of midline in the lower left quadrant.

• Patient is a 29-year-old African-American woman, para 2-1-1-3. Her first pregnancy was full term, delivered by cesarean section because of a double footling breech presentation; weight, 7 pounds 2 ounces. Her next two pregnancies were vaginal deliveries after cesarean section. The first infant weighed 7 pounds 7 ounces, and the second one weighed 5 pounds 6 ounces. Patient had one elective termination of pregnancy at 8 weeks between her first and second children. LMP = 9/3/07. EDC = 6/10/08. Blood pressure is 135/75. Thyroid is mildly enlarged symmetrically without nodularity. Multiple spider angiomas are present over the face, neck, upper chest, and arms. Breasts are symmetrically enlarged, with increased pigmentation of the areolae present. Striae gravidarum are present on the breasts. Chest is clear to percussion and auscultation. Heart rate is 90 and regular. S1 and S2 are normal. No murmurs, gallops, or rubs are heard. Uterus is felt in the abdomen at about a 16-week gestation, which is consistent with dates. Fetal heart rate is 160 with ultrasonic Doppler scan and is located in the midline of the lower abdomen. Bimanual examination reveals a soft lower uterine segment. External os admits a fingertip. Cervix is approximately 2 cm in length. Uterus is globular and smooth. Adnexa is unremarkable. Rectovaginal examination not performed. No edema present. Mild varicosities of both lower extremities are present.

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