Anderson, Tasha D.
08/17/XX
748369
Bockman, Michael
Female
38
163 cm (5 ft 4 inches)
No Known Allergies
Date/Time Orders Progress Notes
02/16/XX 0900 3-hr oral glucose tolerance test. 38 yo, African American G1P0 @28 weeks gestation
History of hypertension
Obese
6th prenatal visit
1st day of last menstrual cycle 07/13/XX
Estimated date of delivery 04/20/XX
Dx: Gestational Diabetes Mellitus
02/16/XX 0900 M. Bockman, MD (4279) Electronic signature
02/16/XX 1400 Give instructions for management of gestational diabetes and dietary recommendations.
02/16/XX 1400 M. Bockman, MD (4279) Electronic signature
Anderson, Tasha D.
08/17/XX
748369
Bockman, Michael
Female
38
163 cm (5 ft 4 inches)
No Known Allergies
Date: 10/19/XX
Reason for visit
Initial Prenatal Visit 		Current history
38 yo, African American G1P0 @ 11 weeks gestation
1st prenatal visit
Obese
1st day of last menstrual cycle 07/13/XX
Estimated date of delivery 04/20/XX
Current medications
Prenatal vitamins 		Health history
Hypertension
General survey
Appears stated age and obese height and weight 		Family history
Family history of diabetes
Review of systems
General Health
Skin: Non-contributory
Head: Non-contributory
Eyes: Denies any blurred vision, does not wear glasses
Ears: WNL
Nose: WNL
Mouth/throat: Denies changes in appetite or thirst
Neck: Non-contributory
Breasts: Tenderness, tingling, increase in size
Respiratory: WNL
Cardiovascular WNL denies edema of extremities
Gastrointestinal: Bowel sounds active x 4 quadrants, reports occasional nausea
Urinary: Denies alterations in urination, urine clear, straw-color
Genitalia: WNL
Sexual Health: Sexually active with partner
Musculoskeletal: WNL
Neurologic: DTRs +2
Hematologic: Lab work pending
Endocrine: Non-contributory 		Measurements:
T: 37.1 °C (98.8 °F)
P: 80/min
R: 16/min
BP: 135 systolic 90 diastolic
Ht/Length: 163 cm (5 ft 4 inches)
Wt: 113 kg
Pain: 0/10 (numeric)
Abuse Screening: Denies risk of domestic violence
Functional assessment
Self-concept: Appears to display positive self image
Activity/exercise: Active, states use of walking for exercise (1 x weekly)
Sleep/rest: Reports sleeping 8 hours per night
Nutrition: Obese
Alcohol: Denies use
Interpersonal relationships: Married
Coping/Stress Management: Denies stress
Immunizations to date
Rubella (titer) immune, varicella, tetanus, pertussis, Hepatitis B, influenza, pneumococcal
Visit Date 10/19/XX 11/16/XX 12/14/XX 1/11/XX 02/08/XX 02/15/XX 02/16/XX
Fundal ht (cm) 15 cm 19 cm 23 cm 28 cm
Weeks gestation 11 wks 15 wks 19 wks 23 wks 27 wks 28 wks 28 wks
FHR 160 150 164 148 152
Presentation vtx vtx
Fetal movement + + + + +
Preterm labor signs denies denies denies denies denies denies
Dilation (cm)
Effacement (%)
Systolic BP 135 132 139 135 138 136
Diastolic BP 90 88 90 85 87 88
Weight 113 kg 115 kg 116 kg 117 kg 119 kg 119 kg
Glucose negative negative negative negative negative negative
Protein negative negative negative negative negative negative
Next Appt 4 wks 4 wks 4 wks 4 wks 1 wk 1 day 2 wks
Notes One hour oral glucose tolerance test
121 mg/dL negative		 Client called unable to make appointment will follow up next week One hour oral glucose tolerance test
142 mg/dL
Perform three hour oral glucose tolerance test		 Three hour oral glucose tolerance test
1000 130 mg/dL;
1100 210 mg/dL;
1200 180 mg/dL:
1300 160 mg/dL
Results positive Dx Gestational Diabetes Mellitus
Electronic Signature Date Name
EG (1019) 10/19/XX E. Green, RN
MB (4279) 10/19/XX M. Bockman, MD
JM (3217) 11/16/XX J. Murphy, RN
MB (4279) 11/16/XX M. Bockman, MD
JM (3217) 12/14/XX J. Murphy, RN
MB (4279) 12/14/XX M. Bockman, MD
JM (3217) 01/11/XX J. Murphy, RN
MB (4279) 01/11/XX M. Bockman, MD
JM (3217) 02/08/XX J. Murphy, RN
JM (3217) 02/15/XX J. Murphy, RN
MB (4279) 02/15/XX M. Bockman, MD
JM (3217) 02/16/XX J. Murphy, RN
MB (4279) 02/16/XX M. Bockman, MD
Anderson, Tasha D.
08/17/XX
748369
Bockman, Michael
Female
38
163 cm (5 ft 4 inches)
No Known Allergies
Date: 10/19/XX
Reason for visit
Initial Prenatal Visit 		Current history
38 yo, African American G1P0 @ 11 weeks gestation
1st prenatal visit
Obese
1st day of last menstrual cycle 07/13/XX
Estimated date of delivery 04/20/XX
Current medications
Prenatal vitamins 		Health history
Hypertension
General survey
Appears stated age and obese height and weight 		Family history
Family history of diabetes
Review of systems
General Health
Skin: Non-contributory
Head: Non-contributory
Eyes: Denies any blurred vision, does not wear glasses
Ears: WNL
Nose: WNL
Mouth/throat: Denies changes in appetite or thirst
Neck: Non-contributory
Breasts: Tenderness, tingling, increase in size
Respiratory: WNL
Cardiovascular WNL denies edema of extremities
Gastrointestinal: Bowel sounds active x 4 quadrants, reports occasional nausea
Urinary: Denies alterations in urination, urine clear, straw-color
Genitalia: WNL
Sexual Health: Sexually active with partner
Musculoskeletal: WNL
Neurologic: DTRs +2
Hematologic: Lab work pending
Endocrine: Non-contributory 		Measurements:
T: 37.1 °C (98.8 °F)
P: 80/min
R: 16/min
BP: 135 systolic 90 diastolic
Ht/Length: 163 cm (5 ft 4 inches)
Wt: 113 kg
Pain: 0/10 (numeric)
Abuse Screening: Denies risk of domestic violence
Functional assessment
Self-concept: Appears to display positive self image
Activity/exercise: Active, states use of walking for exercise (1 x weekly)
Sleep/rest: Reports sleeping 8 hours per night
Nutrition: Obese
Alcohol: Denies use
Interpersonal relationships: Married
Coping/Stress Management: Denies stress
Immunizations to date
Rubella (titer) immune, varicella, tetanus, pertussis, Hepatitis B, influenza, pneumococcal
Electronic Signature Date Name
EG (1019) 10/19/XX E. Green, RN