Post-partum without complications

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Reference no: EM133822281

Case. Teresa.

History of Present Illness (HPI): Teresa is a 34-year-old Hispanic G2P2002. She presents to your office today at 10-weeks post-partum (PP) for her 6-week PP check. She underwent a C-section for failure to progress following a 20-hour labor with Pitocin augmentation. She was discharged from the hospital on day 2 post-partum without complications. Teresa has had difficulty with breast feeding due to discomfort in her suture line and terrible pain in her right breast since her discharge from the hospital. She reports occasional chills- she has not measured her temperature at home. Teresa was seen by the lactation consultant while in the hospital but "nothing is working" and her son "cries all the time". She is afraid to feed her son formula as her mother-in-law wants her to "keep trying to breastfeed". Teresa tells you she feels as if she has failed her son- "it was so easy with my first baby, I know my husband
thinks I am a bad mother".
Prior medical history: None. Prior surgical history: Appendectomy (2000) Current medications: Prenatal vitamins, stool softener. Allergies: None
OB- GYN History: NSVD (2019) healthy female 7lb 10oz; C-section healthy male 8 lbs. 8 oz as per HPI.
Menarche age 12, cycle length- 5 days- frequency every 28 days- 4-5 tampons per day. No history of
sexually transmitted infections (STDs). History of abnormal pap smear in 2019 which was followed by a normal colposcopy. Last pap (during recent prenatal care) reported normal. HIV negative.
LMP: First PP menstrual cycle last week. Has not resumed sexual activity PP. Contraception history: Oral contraceptives, condoms.
Social history: Lives with husband, mother- in- law, and children. Stay at home mom. Denies EtOH or recreational drug use, never smoker. Her family speaks Spanish at home; she is fluent in English.
Family history: Unremarkable.
Review of Systems (ROS): Negative except as noted in HPI. Physical Exam (PE)
VS: BP: 110/70, P: 90, RR: 18, T: 38.4, Weight: 132 lbs.
Teresa's C-section suture line is healing well without erythema or tenderness. No vaginal discharge or lesions, no cervical motion tenderness (CMT), uterus normal size firm and non-tender. On breast exam, you do note an erythematous, swollen, and painful area to the right breast. Her physical exam is otherwise unremarkable.

Reference no: EM133822281

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