November 28th, 2022 – 19:45
KJ, 27F, Black, Married, Brooklyn, NY
Informant: Patient, reliable
Referral Source: Self
Chief Complaint: Decreased fetal movement x 2 days
History of Present Illness:
KJ is a 27-year-old G2P0010 Female at 33w3d gestation, no significant PMHx, uncomplicated pregnancy, presenting for reports of decreased fetal movement x 2 days. Patient reports that over the past 2 days she has noticed a significant decrease in the amount of movement she feels compared to baseline. She denies any preceding trauma or injury. She has not tried any methods at home to try to illicit fetal movement, such as drinking cold water or eating a sugar-filled snack. Last fetal movement was felt 1 hour prior to arrival to L&D triage (approximately 19:15). Of note, patient states that she had an US performed at her regularly scheduled OB appointment this morning and was told by the provider that they could see the baby moving during the sonogram, but she was unable to feel the movement at that time. Denies any contractions, vaginal bleeding, loss of fluids, vaginal discharge, dysuria, urinary frequency/urgency, vomiting, or diarrhea. Denies any toxic symptoms of preeclampsia including headache, vision changes, SOB, or RUQ pain. No recent travel, sick contacts, or known exposures to COVID-19.
Past Medical History:
- Childhood illnesses: Denies.
- Adult illness: Denies history of migraines, asthma, DM, HTN, thyroid disease, bleeding disorders, or CA.
Past Surgical History:
- B/L femoral hernia repair, 1996, no complications.
- Cosmetic B/L labial reduction, 2017, no complications.
Medications: Prenatal vitamins daily. Denies other daily medications.
Allergies: Latex (rash, denies difficulty breathing or anaphylaxis), NKDA, NKFA.
Immunizations: Childhood vaccines UTD. Tetanus up to date as of 2021. COVID-19 vaccine & 2022 flu vaccine up to date.
GYN history: Denies history of ovarian cysts, uterine fibroids, abnormal PAP results, or STIs. Last PAP 2021, normal as per patient.
OB history: G2P0010.
- G1 – medical VTP at 6 weeks gestation, 2020, no complications.
- G2 – current pregnancy, regular prenatal care throughout pregnancy, passed GCT at 28 weeks, no history of elevated BP during pregnancy, NIPT WNL, anatomy scan WNL, GBS swab not yet performed, last EFW (as of 11/5/22) 1800g.
- Substance Abuse: Endorses social ETOH consumption & social marijuana smoking prior to pregnancy. Denies cigarette smoking, ETOH consumption, or illicit drug use during this pregnancy.
- Diet/Exercise/Sleep: Endorses well-balanced diet, regular exercise 3-4 days/week, & 7-8 hours sleep/night.
- Living conditions: Lives at home with mother & partner in apartment in Brooklyn.
- Occupation/Education: Works as hair stylist.
Review of Systems:
- General: Denies fever, chills, or body aches.
- Skin: Denies rashes, dryness, lesions, or color changes.
- Head: Denies headache, recent head trauma/injury.
- Eyes: Denies visual changes, redness, discharge, pruritis, or photophobia.
- Ears: Denies pain, fullness, change in hearing, discharge, or tinnitus.
- Nose/sinuses: Denies nasal discharge, congestion, epistaxis, or trauma.
- Mouth/throat: Denies sores, bleeding gums, hoarseness, or difficulty swallowing.
- Neck: Denies pain, limitation of movement, or lumps.
- Respiratory: Denies cough, wheezing, or SOB.
- Cardiac: Denies chest pain or palpitations.
- GI: Denies abdominal pain, nausea, vomiting, diarrhea, or constipation.
- GU: Denies dysuria, hematuria, frequency, hesitancy, or vaginal bleeding/discharge.
- PV: Denies cyanosis or temperature changes of extremities.
- MS: Denies joint pain, stiffness, or deformities.
- Hematologic: Denies easy bleeding or bruising.
- Endocrine: Denies heat/cold intolerance, flushing, sweating, or unintentional weight loss.
- Neurologic: Denies dizziness, lightheadedness, numbness, tingling, weakness, syncope, LOC, or seizures.
- Psychiatric: Denies insomnia, anxiety, depression, hallucinations, or SI/HI.
General: 27F, A&Ox3, sitting in triage, dressed, well groomed, not in acute distress. She is not ill-appearing or diaphoretic.
- BP (Seated) 124/72
- P: 85bpm, regular
- R: 14 breaths/minute, unlabored
- T: 98.6F (37.0C), oral
- O2 Sat: 99% room air
- Height: 63in – Weight: 138lbs – BMI 24
Skin: Warm, dry. No rashes or lesions. No nail cyanosis or clubbing.
HEENT: Normocephalic, atraumatic. PERRL, EOMI. No external nasal deformity. B/L nares patent without obvious discharge. Lips pink and moist without obvious lesions. Mucosa pink and moist. No tonsillar enlargement, erythema, or exudates.
Neck: Supple. FROM intact without pain. No lymphadenopathy. Trachea midline. Thyroid smooth without enlargement or nodules.
Lungs: Lungs CTA B/L. No increased work of breathing or accessory muscle use. No rales, rhonchi, or wheezing.
Cardio: No JVD. Normal S1, S2. No murmurs, rubs, clicks, or gallops.
Abdomen: Abdomen gravid, soft, non-tender. Fundal height appropriate for gestational age. Normoactive bowel sounds x 4 quadrants. No hepatosplenomegaly. No CVA tenderness.
Pelvic exam: Deferred at this time, given recent evaluation at OB clinic this morning.
Rectal exam: Deferred.
Extremities: Full ROM intact x 4 extremities. No warmth, edema, or tenderness to palpation. No calf tenderness B/L. Distal pulses 2+ B/L.
Neuro: AOx3. CN II-XII grossly intact. Strength 5/5 x 4 extremities.
Labs and Imaging:
Transabdominal US: Cephalic position. Anterior placenta. BPP 8/8.
NST: Baseline 130 bpm, moderate variability, + accelerations, – decelerations. Overall reactive & reassuring.
Assessment & Plan:
Decreased fetal movement – likely fetal sleep or anterior placental position preventing maternal ability to detect fetal movement; less likely fetal compromise
Explained to patient reassuring results of NST & BPP performed in triage. Encouraged patient to continue regular OB follow up at OB/GYN clinic. Advised patient to continue monitoring fetal movement at home & to perform “kick counts” over a 2 hour period of rest (normal fetal movement approx. 10 kicks over 2 hours of maternal rest). Strict return precautions given to return to OB/GYN clinic or L&D triage immediately for any decreased fetal movement from baseline, absent fetal movement, regular contractions, vaginal bleeding, or loss of fluids.