History
Identifying Data:
Full Name: MH
Address: N/A
Date of Birth: N/A
Date & Time: 11/14/2023, 2:00 pm
Location: Woodhull
Religion: N/A
Source of Information: Self
Reliability: Reliable
Source of Referral: Self
Mode of Transport: N/A
Chief Complaint: “I’ve had dizziness and numbness and tingling in hands and legs” x 1 week.
26 y/o female G3P1011 at 31w5d gestational age with an estimated date of delivery of 1/10/24, last seen 8/28/23, presents c/o dizziness, numbness and tingling in bilateral upper and lower extremities for 1 week. Patient notes she pins and needles sensation in fingers, elbows and knees; however, she does not always have it in upper and lower extremities simultaneously. Pt also states at times she is unable to described abnormal sensation. Pt reports episodes occur only during the day and last hours and resolve spontaneously without intervention. She states she has never experienced this sensation before in the past. She also notes the dizzy feeling is intermittent and last less than 1 min and resolves spontaneously. Pt also reports malodorous, vaginal discharge. Denies new sexual partners, fever, chills, nausea, vomiting, diarrhea, heaving bleeding, loss of fluid, chest pain, SOB, weakness, recent sick contacts, recent travel, headache, or focal deficits.
Initial DDx:
Vitamin B12 deficiency
Peripheral neuropathy
Preeclampsia
Past Medical History:
Morbid Obesity
Asthma
Chlamydia
Gonorrhea
Heart murmur
Hyperlipidemia
Iron deficiency
Vitamin D deficiency
Childhood Illnesses- N/A
Immunizations – Up to date
Screening test and results – pap smear 6/2021, normal
Past Surgical History:
Bariatric surgery 2019
Roux-en-Y 2023
C-section 2022
Denies any blood transfusions.
Medications:
Ergocalciferol
Ferrous sulfate
Albuterol
Prenatal vitamins
Allergies:
Latex, itching
Peanuts, rash
Family History:
Daughter – alive and well
Mother – alive and well
Dad – alive and well
Maternal grandmother – alive, h/o breast cancer
Denies family h/o asthma, kidney disease, diabetes
Social History:
Patient lives with boyfriend.
Habits –Denies drinking coffee. No history of smoking, alcohol abuse, or history of illicit substances.
Travel – No recent travel.
Diet – Has a well-balanced diet.
Exercise – Denies exercise.
Safety measures – Admits to wearing a seatbelt.
Sexual Hx – Has one sexual partner who is her boyfriend. H/o of chlamydia.
Review of Systems:
General – Denies fever, recent weight loss or gain, chills, night sweats, loss of appetite or generalized weakness/fatigue.
Skin, hair, nails – Denies changes in texture, excessive dryness or sweating, discolorations, pigmentations, moles/rashes, pruritus or changes in hair distribution.
Head – Denies headache, head trauma.
Eyes – Denies eyelid swelling, painful eye movements, visual disturbances, eye redness, lacrimation, pruritus. Does not wear glasses.
Ears –Denies ear pain, deafness, discharge, tinnitus or use of hearing aids.
Nose/sinuses –Denies runny nose, discharge, epistaxis, or nasal polyps.
Neck – Denies localized swelling/lumps or stiffness/decreased range of motion
Breast – Denies lumps, nipple discharge, or pain.
Mouth/throat –Denies voice changes, sore throat, bleeding gums, sore tongue, mouth ulcers, or use dentures.
Pulmonary system –Denies cough and dyspnea on exertion. Denies wheezing, hemoptysis, cyanosis, orthopnea, or paroxysmal nocturnal dyspnea (PND).
Cardiovascular system –Denies irregular heartbeat, chest pain, edema/swelling of ankles or feet, syncope or known heart murmur.
Gastrointestinal system – Usually has regular bowel movements daily. Denies nausea, diarrhea and abdominal pain. Denies vomiting, intolerance to specific foods, dysphagia, pyrosis, unusual flatulence or eructations, jaundice, hemorrhoids, or constipation.
Genitourinary system – Denies dysuria and blood in urine. Denies nocturia, urinary frequency, urgency, oliguria, polyuria, incontinence, or flank pain.
Menstrual/Obstetrical – Denies breast pain, masses, skin changes, bleeding or discharge from nipple. Pap smear up to date.
Musculoskeletal system –Denies pain or muscle/joint pain from arthritis. Denies deformity or swelling, or redness.
Nervous – Paresthesia of extremities. Denies loss of strength or weakness. Denies seizures, headache, ataxia, change in cognition.
Peripheral vascular system – Denies peripheral edema, intermittent claudication, coldness or trophic changes, varicose veins, or color changes.
Hematological system – Denies anemia, easy bruising or bleeding, lymph node enlargement, or history of DVT/PE. Denies blood transfusion.
Endocrine system – Denies polyuria, polydipsia, polyphagia, heat or cold intolerance, excessive sweating, hirsutism, or goiter
Psychiatric – Denies depression/sadness, anxiety, OCD or ever seeing a mental health professional.
Physical
General: Female appears clean & casually-groomed, alert & active. Does not appear to be in acute distress.
Vital Signs: BP: (R) 108/54 (sitting) P: 80 beats/min, regular
R: 18 breaths/min, unlabored
O2 Sat: 100 % on room air
T: 36.66 degrees C (oral)
BMI: 40.60 kg/m2
Head, Skin, & Nails
Hair: Average quantity and distribution. Black color. Straight texture. No evidence of lice or seborrheic dermatitis.
Skin: Warm and moist, smooth texture, good turgor.
Nails: No clubbing, capillary refill <2 seconds in upper and lower extremities
Head: Normocephalic, atraumatic, non-tender to palpation throughout.
Eye Exam
Eyes – Symmetrical OU. No strabismus, exophthalmos or ptosis. Sclera white, cornea clear, conjunctiva pink. EOMs intact with no nystagmus.
Ear Exam
Ears – Symmetrical and appropriate in size. No lesions/masses/trauma on external ears. No discharge/foreign bodies in external auditory canals AU.
Nose & Sinuses Exam
Nose – Symmetrical/no masses/lesions/deformities/trauma/discharge. Nares patent bilaterally/nasal mucosa pink & well hydrated. No discharge noted on anterior rhinoscopy. Septum midline without lesions/deformities/injection/perforation. No foreign bodies.
Sinuses – Non-tender to palpation and percussion over bilateral frontal, ethmoid and maxillary sinuses.
Mouth & Pharynx
Lips – Pink, moist; no cyanosis or lesions.
Mucosa – Pink ; well hydrated. No masses; lesions noted. No leukoplakia.
Palate – Pink; well hydrated.
Teeth – Good dentition / no obvious dental caries noted.
Gingivae – Pink; moist. No hyperplasia; masses; lesions; erythema or discharge.
Tongue – Pink; well papillated; no masses, lesions or deviation.
Oropharynx – Well hydrated; no injection; exudate; masses; lesions; foreign bodies.
Tonsils present with no injection or exudate. Uvula pink, midline, no edema, lesions
Neck Exam
Neck- Trachea midline. No masses; lesions; scars; pulsations noted. Supple; non-tender to
palpation. FROM; no stridor noted. 2+ Carotid pulses, no thrills; bruits noted bilaterally, no cervical adenopathy noted.
Thyroid – Non-tender; no palpable masses; no thyromegaly; no bruits noted.
Thorax & Lungs:
Chest – Symmetrical, no deformities, no trauma, Respirations unlabored and no use of accessory muscles noted. Lat to Ap diameter 2:1. No tenderness to palpation throughout.
Lungs – No wheezing, rales, stridor, or rhonchi. Chest expansion and diaphragmatic excursion symmetrical. Tactile fremitus symmetric throughout.
Cardiac Exam
Heart: Carotid pulses are 2+ bilaterally without bruits. Regular rate & rhythm. S1 & S2 are distinct with no murmurs, S3 or S4. No splitting of S2 or friction rubs appreciated.
Abdominal Exam: gravid uterus, soft, non-tender. No scars, striae, or pulsations noted. Bowel sounds normoactive in all four quadrants with no aortic/iliac or femoral bruits. Pt is non-tender to palpation in all four quadrants. (-) guarding. (-) obturators sign, (-) psoas signs, (-) rebound tenderness. No hepatosplenomegaly to palpation, no CVA tenderness appreciated.
Genitalia: External genitalia without erythema or lesions. Vaginal mucosa pink without inflammation, erythema or discharge. Cervix closed, pink, and without lesions or discharge. No cervical motion tenderness. Uterus anterior, midline, smooth, non-tender and not enlarged. No adnexal tenderness or masses noted. No inguinal adenopathy.
Rectal: Rectovaginal wall intact. No external hemorrhoids, skin tags, ulcers, sinus tracts, anal fissures, inflammation or excoriations. Good anal sphincter tone. No masses or tenderness. Trace brown stool present in vault.
Neurologic:
Mental status: Patient is alert. Cranial nerves II-XII intact. Recent and remote memory is intact, attention, abstract thinking, and new learning ability are intact. Pt has good muscle bulk and tone with strength 5/5, no fasciculations. Cerebellar: Rapid alternative movements, finger to nose intact. Gait including normal stride, on toes, on heels, and tandem walking intact. Negative Romberg and Pronator Drift. Sensory: Pinprick, light touch, graphesthesia, stereognosis, position and vibration intact bilaterally.
Reflexes:
Biceps Triceps Brachioradialis Patellar Ankle/Achilles Babinski
Right 2+ 2+ 2+ 2+ 2+ absent
Left 2+ 2+ 2+ 2+ 2+ absent
Peripheral Vascular: Extremities are normal in color and temperature, no edema. Pulses are 2+ bilaterally in upper and lower extremities. No bruits noted. No clubbing or cyanosis. No stasis changes or ulcerations noted.
Musculoskeletal (Upper Extremity): No soft tissue swelling / erythema / ecchymosis / atrophy / or deformities in bilateral upper and lower extremities. Non-tender to palpation/no crepitus noted throughout. FROM of all upper and lower extremities bilaterally. No evidence of spinal deformities.
Assessment:
26 y/o female G3P1011 at 31w5d with paresthesia of fingers, elbows, and knees of bilateral upper and lower extremities for 1 week. Physical exam with no significant findings. Admit for workup to r/o nutritional deficiency vs neurological pathology.
Plan:
Discussed speculum and vaginal exam with patient. Start IV fluids. Will order labs including CBC, CMP, UA and urine culture, Ferritin, TBIC, Hemoglobin A1c, vaginitis panel, Gonorrhea and Chlamydia, magnesium, vitamin D, folate, and Vitamin B12. Neuro and medicine consult. Monitor FHR and contraction monitoring. Discussed staying with one prenatal care practice for prenatal care. Pt scheduled for appointment in 2 days.
