A 34-year-old woman presented to the clinic 35 weeks pregnant, she has fatigue that started earlier in her pregnancy, dyspnea on exertion, and is restless during sleep. She has a history of menorrhagia, and a previous preterm delivery due to severe preeclampsia. Her pulse is103; BP- 140/90 CBC with leukocytes, 10.8 × 109/L; Hb, 8.9 g/dL; HCT- 28.4%; MCV- 72 fL, platelets- 272 × 109/L, RBC- 18. 4 weeks earlier it was (for Hb, 8.5- Hct, 26.8%, MCV-78 ), oral iron had been started by an OB but it caused a lot of constipation.
With this patient in mind, address the following in your Focused Note Template:
Assignment:
- Subjective: What details did the patient provide regarding her personal and medical history?
- Objective: What observations did you make during the physical assessment?
- Assessment: What were your differential diagnoses? Provide a minimum of three possible diagnoses. List them from highest priority to lowest priority. What was your primary diagnosis and why?
- Plan: What was your plan for diagnostics and primary diagnosis? What was your plan for treatment and management, including alternative therapies? Include pharmacologic and nonpharmacologic treatments, alternative therapies, and follow-up parameters, as well as a rationale for this treatment and management plan.
- Reflection notes: What would you do differently in a similar patient evaluation?
A 34-year-old woman presented to the clinic 35 weeks pregnant, she has fatigue that started earlier in her pregnancy, dyspnea on exertion, and is restless during sleep. She has a history of menorrhagia, and a previous preterm delivery due to severe preeclampsia. Her pulse is103; BP- 140/90 CBC with leukocytes, 10.8 × 109/L; Hb, 8.9 g/dL; HCT- 28.4%; MCV- 72 fL, platelets- 272 × 109/L, RBC- 18. 4 weeks earlier it was (for Hb, 8.5- Hct, 26.8%, MCV-78 ), oral iron had been started by an OB but it caused a lot of constipation.
With this patient in mind, address the following in your Focused Note Template:
Assignment:
- Subjective: What details did the patient provide regarding her personal and medical history?
- Objective: What observations did you make during the physical assessment?
- Assessment: What were your differential diagnoses? Provide a minimum of three possible diagnoses. List them from highest priority to lowest priority. What was your primary diagnosis and why?
- Plan: What was your plan for diagnostics and primary diagnosis? What was your plan for treatment and management, including alternative therapies? Include pharmacologic and nonpharmacologic treatments, alternative therapies, and follow-up parameters, as well as a rationale for this treatment and management plan.
- Reflection notes: What would you do differently in a similar patient evaluation?