CASE PRES CHN

No major health issues or hospitalizations

Client A.D.L. has not been admitted to the hospital for any illness or disease and has no known allergies or mental health conditions.

Miscarriage and D&C

She experienced a miscarriage at age 21 after a fall down the stairs and underwent a dilation and curettage (D&C) procedure.

Subsequent pregnancies

After the miscarriage, she became pregnant again and later gave birth to two children:

First child

A baby girl born on June 9, 2012, at Mercy Maternity Clinic.

Second child

Another baby girl was born on April 6, 2018, at SPMC.

Currently 8 months pregnant

She is in the later stages of a healthy, uncomplicated pregnancy with no reported complications.

Positive pregnancy experience

Vital signs were consistently normal throughout the pregnancy, and the pregnancy progressed on track with no concerns.

Diet

She maintains a balanced diet, focusing on nutritious meals, especially vegetable soups, and avoids excess rice and soda.

Exercise

She stays active by walking daily, helping her maintain energy and overall well-being.

Routine prenatal care

She attends regular prenatal visits, with monthly check-ups initially and bi-monthly visits after 5 months, ensuring thorough monitoring and reassurance.

Routine tests

Recent tests for albumin and sugar returned negative, indicating no concerns.

Family support

Her family, especially her husband, plays a significant role in her emotional well-being, providing support and involvement throughout the pregnancy, which contributes to a positive and nurturing environment.

Mental health and relationships

A supportive relationship with her husband and a strong family network has helped her feel cared for and reassured.

Age

33 years old, 8 months pregnant.

Appearance

Well-groomed, calm, alert, and cooperative. The posture is erect, and the movements are purposeful, though waddling is due to pregnancy.

BP

120/80 mmHg

Pulse

71 bpm

Respiratory Rate

20 bpm

Temp

36°C

Skin

Hydrated, even tone, no rashes or cyanosis. Symmetric facial features. Weight: 66 kg, influenced by pregnancy.

Cognition

Alert, oriented, clear speech with no cognitive issues.

Skin

Smooth, intact, no dryness or lesions, with dark patches (chloasma) on the face due to pregnancy.

Hair

Slightly dry, straight, black, and healthy. No thinning or patchiness.

Nails

Healthy, capillary refill time: 2 seconds, indicating good circulation.

Head

Symmetrical with no abnormalities. Facial movements are normal.

Neck

Symmetrical, free of masses or tenderness, no deviation in the trachea. No lymph node enlargement.

Thyroid

Non-enlarged, no nodules.

Eyes

Visual field normal, pupils responsive to light and accommodation. No abnormalities in the sclera, conjunctiva, or cornea. Visual acuity decreased at long distances (common in pregnancy).

Ears

Symmetrical, no deformities, no excess cerumen, and clear auditory canal.

Nose

Slightly larger due to pregnancy, but no blockages. The mucosa is pink and moist.

Oral Cavity

No issues with swallowing or speech. No lesions, redness, or swelling in the mouth or tonsils.

Thorax

Symmetrical, normal chest ratio (1:2). No abnormal breathing movements, and the chest expands symmetrically.

Breathing

Unlabored, clear breath sounds, normal lung percussion, no abnormal sounds.

Heart

Normal heart rate (72 bpm), no murmurs or irregularities.

Peripheral Circulation

Pulses are strong and equal, and there is no swelling, varicose veins, or discomfort.

Shape

Rounded and consistent with pregnancy. No visible abnormalities, or stretch marks present (linea nigra visible).

Palpation

Soft abdomen, firm uterus, no tenderness, or masses. Fetal movements are palpable. Fundal height: 35 inches.

Fetal Position

Left occiput posterior, head not yet engaged.

Asymmetry

Right breast slightly larger, with previous breastfeeding history noted. Stretch marks and darkened areolas.

Nipples

Everted, larger, and darker; crack in the right nipple noted (pre-existing condition). No masses, or discharge.

Posture

Waddling gait, forward shift due to pregnancy weight.

Muscle Tone

Intact with no weakness. Mild edema in feet and ankles.

Joint Mobility

Normal range of motion in most joints; decreased range in hips and pelvis. Mild discomfort in the lower back during activity.

Consciousness

Alert and oriented, Glasgow Coma Scale (GCS) score 15.

Cranial Nerves

All cranial nerves functioning normally. Sensory and motor responses are intact, no abnormalities in speech, vision, or motor skills.

Fundal Grip

Fetal head felt, indicating breech presentation.

Umbilical Grip

Fetal limbs felt, indicating flexed position.

Pawlik's Grip

Head still floating, not yet engaged in the pelvis.

Pelvic Grip

The head is firm, round, and flexed (vertex presentation).