Case description for C-Takes documenting:
Setting: Outpatient.
Specialty: OB/GYN. 
Note detail level (1-5): 2.
Level of abbreviation (Low/Medium/High): Medium.

HPI/CC: Mrs. X is a 22 yo G1P0 at 14 and 2 in an uncomplicated pregnancy who presents to the clinic today with a CC of continued MSK of 1st-3rd metacarpophalangeal joints s/p MVA 4 weeks ago. She is currently in 4/10 pain and is wearing a brace on her right hand. It is significantly interfering with her ability to perform her work as a waitress. FHTs@154. Currently has a UTI being managed by another provider. Patient reports some nausea that she associates with the pregnancy and some SOB also, she feels, associated with the pregnancy. 

ROS: Patient denies vomiting, night sweats, fever, cp, vaginal bleeding/discharge
PMHx: Migraines. 
SHx: Not contributory.
FamHx:Not contributory.
SocHx: Asked about domestic violence. Patient denies domestic violence at home.
Meds: Fioricet for migraines. Tylenol, PNV, and an antibiotic she could not recall for a UTI diagnosed three days by another provider. 

Vits: BP 121/64, HR 97, T 98.7
PE:
Reveals a slightly overweight healthy appearing woman of her stated age and gestation. After removing right hand brace, joints appear slightly swollen compared to the contralateral side. No erythema, heat. Slightly decreased hand strength/ROM. No tingling, numbness.

Labs/Anc: FHT 154. Radiograph done of wrist at time of accident - does not fully visualize the affected area. From what can be seen: no fractures.

A/P: Mrs. X is a 22yo G1P0 at 14 and 2 with FHTs@154 s/p MVA with right hand pain. Reassure her. Give her ibuprofen and council her not to take it after 21 weeks. 

