General Appearance

Vitals: BP, pulse, respirations, temperature.

HEENT: Funduscopy, facial edema, jugular venous distention.

Chest: Wheezes, rhonchi.

Cardiovascular: Rhythm, S1, S2, murmurs.

Abdomen: Fundal height, Leopold's maneuvers (lie, presentation).

Estimated fetal weight (EFW), tenderness, scars.

Cervix: Dilatation, effacement, station, position, status of membranes, presentation. Vulvar herpes lesions.

Extremities: Cyanosis, clubbing, edema.

Neurologic: Deep tender reflexes, clonus.

Prenatal Labs: Obtain results of one hour post glucola, RPR/VDRL, rubella, blood type, Rh, CBC, Pap, PPD, hepatitis BsAg, UA, C and S. Current Labs: Hemoglobin, hematocrit, glucose, UA; urine dipstick for protein.

Assessment: Intrauterine pregnancy (IUP) at 40 weeks, admitted with the following problems:

Plan: Anticipated type of labor and delivery. List plan for each problem.

H. Extremities. Severe lower extremity or hand edema suggests preeclampsia. Deep-tendon hyperreflexia and clonus may signal impending seizures.

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Acne is a name that is famous in its own right, but for all of the wrong reasons. Most teenagers know, and dread, the very word, as it so prevalently wrecks havoc on their faces throughout their adolescent years.

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