PMH

Active problems: HTN 

Inactive problems: Severe preeclampsia with 1st pregnancy 

Hospitalizations: None, other than previous pregnancies

Immunizations: up to date tetanus shot (3 years ago). She never got any of the COVID 19 vaccines

PSH

C-section with 1st pregnancy

Allergies

NKDA

Medications

Labetalol 100mg by mouth twice a day (patient not taking this, unable to fill prescription)

SH

Substances: +Tobacco, 1⁄2 ppd, trying to cut down due to pregnancy. No alcohol, no illicits

Diet: fast food, junk food. 

Exercise: no formal exercise, works on her feet 8 hours a day

Sexual activity: monogamous with husband, does not use condoms

Home life: Married to Daniel, a veteran who suffers PTSD

2 children; 5 years old daughter, 3 year old son

Occupation: Waitress

Context: Live in a small town, Malta, OH. High level of stress due to husband’s mental health, 2 small children, hectic job and financial issues.

FH

Mother: deceased at 72 y/o lung cancer

Father: living, 75 y/o, HTN, COPD, DM

Brother: living, 40 y/o HTN

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