Marietta Outreach Clinic
Patient Name: Simone Sodo Gender: Female Age: 38
Insurance: Medicaid Number # 1EG4-TE5-MK72
Insurance: Medicaid Number # 1EG4-TE5-MK72
HPI
Ms. Sodo is a 38 year old female who is presenting for a follow up visit to her obstetrician’s remote clinic. She is 15 weeks gestation. She missed her last follow up appointment because she could not get off of work.
She had an elevated blood pressure on her initial visit and was prescribed labetalol 100 mg by mouth twice a day by her OB. However, the pharmacy did not have it in stock. Ms. Sodo never went back to pick up the prescription. She has not checked her blood pressure at home because she does not have a cuff.
She notices her feet tend to get swollen, especially at the end of her shift at work. She has been very stressed out and unable to quit smoking. She complains of some nausea and vomiting
She reports that she has not felt fetal movement yet.
ROS
+ nausea and vomiting
+ minimal lower extremity edema
no fevers or chills
no SOB
no cough
no CP
no changes in bowel habits
no abdominal pain/contractions
no urinary symptoms
no vaginal bleeding
no numbness or tingling
no weakness
no vision changes
no headache
Physical Exam
Temp.: 97.4° HR: 88 BP:147/95 RR:12 BMI: 35
FHR: 130 by doppler
Urinalysis: no protein, no glucose
General: Overweight black female appears fatigued
Eyes: no scleral icterus
CVS: regular rate and rhythm, +2/6 systolic ejection murmur. no S3, + S4
Lungs: clear to auscultation, no rales, wheezes or rhonchi
Abd: obese, + bowel sounds, soft, nontender, nondistended. Fundal height palpable halfway to umbilicus.
Extr: trace pedal edema, no clubbing or cyanosis.