CHART NOTE
HISTORY
Patient is here for examination. She was complaining of some heaviness in her chest. On examination, her blood pressure was noted to be 140/90. Repeat is 142/92. After a nonstress test, blood pressure x2 was 130/82 and 132/84.
On examination, the fundal height was 44 cm. Fetal heart tones are reactive x2. There was an occasional contraction noted. Cervix is noted to be closed and long with the cephalic head presenting. DTRs are 1+, and edema is also noted to be 1+ in the pretibial area.
IMPRESSION
1. Twin gestation at 36 weeks, with possible mild
pregnancy-induced hypertension.
pregnancy-induced hypertension.
2. There is no evidence at this time of any toxemia.
3. CBC with platelets and chemistry screen was drawn.
Patient is to return in 2 days. Should blood pressure again be elevated or should she have any signs of toxemia, the patient may need to be scheduled for induction and delivery.
FOOTNOTE
The abbreviated forms were expanded in the report.
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