Gestational Age
...of Exam: 09/18/08 Sex: F
GA: 40 weeks 2 days by dates Ballard Score: 40 corresponding to 40 weeks
Weight (gms): 3886 gm Length (cm): 51.7 cm
Head Circumference: 34.7 cm Chest Circumference: 32.3 cm
Classification: AGA
Temperature: 36.8 degrees C Pulse: 136 RR: 42
BP: 60/32 Mean: 42 Extremity: left lower leg
Pulse pressure: 28
2. Identifying Information: (maternal data)
Age: 17 Marital Status: Single Race: Hispanic
Occupation: student Religion: Catholic
Highest Education Level: Currently a high school senior
Medical Insurance: Aetna
3. General Health Status:
Injuries/Hospitalizations/ Surgeries: None
Allergies: No known allergies
Health Habits:
Patient denies: smoking, alcohol use, illicit drug use, difficulty sleeping, use of caffeine, use of prescription medications, hx of diabetes, hx of heart disease, hx of injuries, hx of respiratory problems, hx of mental illness, hx of kidney disease, hepatitis or liver disease, hx of seizure disorders, hx of hypertension, hx of blood disorders (smoking, exercise, sleeping, dietary, use of coffee, alcohol, other drugs Kyle, you can take out what is in parentheses…it’s just there as a prompt for the students.
Patient exercises daily consisting of 30 minute to 1 hour walks good for her!. Meds taken during this pregnancy include prenatal vitamins.
4. Family History (mother):
Genetic Problems: MGM: hypercholesterolemia, HTN, MGF: prostate cancer, MA: breast cancer. Patient denies family hx of diabetes, kidney disease, neurological disease, or genetic...
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