Progress Notes - Welcome to the Section on Women's Health- Section by HC120928235831


									                     Progress Notes
                              Page 1
1/19/2003 CC: Vaginal bleeding, missed abortion
0900      HPI: This 36 year old, G-1, P-0, at 12 weeks of pregnancy
              experienced vaginal bleeding. Ultrasound scan showed
              a 7-week size fetus with no heartbeat, and a swiss
              cheese appearance of the placenta, suggesting molar
              degeneration or a partial mole.

                LMP 10/27/02
                Menses regular, Q 28 x 4
                +UCG 11/30/02

           PMH: None
           Meds: PNVs
           Allergies: None
           Habits: No smoking, no EtOH, no Illegal drugs
           ROS: Negative

           Physical Exam
           VS: TemP: 98.6, P72, R14, BP 100/60, Wt 122#
           Gen: Alert and oriented
           HEENT: WNL
           Heart: NSR, no murmur
           Lungs: Clear
           Breasts: normal
           Abd: Soft, non-tender and no masses
           Pelvic: No bleeding. Uterus is enlarged to 14 week size. No
                adnexal masses. No tenderness.
             Progress Notes
                      Page 2
Lab: UCG positive, Quant pending

     1. Missed abortion with possible molar degeneration or
        partial mole

     1. CBC
     2. UA
     3. Chest x-ray
     4. Quant HCG now and in 2 weeks
     5. D&C
     6. Karyotype of products of conception
     7. Further management pending results of D&C

                                           Mike Hughey, MD

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