Case description for C-Takes documenting:
Setting: Outpatient.
Specialty: OB/GYN. 
Note detail level (1-5): 3.
Level of abbreviation (Low/Medium/High): Medium.

Mrs. X is a 31 yo G4P3003 at 25+1 weeks who presents with a CC of leakage of fluid after urinating and while walking. Her pregnancy has been uncomplicated to date. The leakage began two days ago in the afternoon. It has continued until today, when she came in to the clinic at the urging of a friend. It is worse when she walks and after urination. The fluid appears clear on a pad. It is not copious. She thinks that it may be coming from her vagina, but she is unsure. Denies gush of fluid, VB, CTX. There is +FM.

ROS: She denies urinary symptoms, cp/sob/n/v/ns/ha/changes in vision.
GynHx: Last pap last year. No history of abnormal paps. Chlamydia in college. Three previous pregnancies resulted in uncomplicated SVDs. Pelvis proven to 6lbs 6oz. Last pregnancy complicated by GDM.
PMHx: Pt reports congenital heart murmor.
SurgHx: Non contrib.
FamHx: Non contrib.
Meds: PNV - denies any other medications.
Allergies: NKDA

Vit: Tc 97.9 BP 111/66 HR 80 RR 18 SpO2 100% 
PE: Well appearing AA woman who appears her stated age and in no acute distress.
CV: No m/r/g, rrr.
Abd: Gravid abdomen consistent with gestational age. Gross fetal movement noted.
Gyn: No leakage of urine w/ cough. Speculum exam: Diffuse vaginal sidewall tenderness, scant amount of off-white cervical discharge. No odor. No pooling in posterior fornix. Closed cervical os without friability. No blood noted in vault nor otherwise abnormal discharge.

Labs/Studies:
KOH/Wet prep showed no clue cells/spores/hyphae.
Fern test neg. Nitrazine test neg.
Gon/Chlamydia pending.
US: AFI 17cm. Observed fetal cardiac activity.
NST: reactive.
FHR: 140s w/ pos accels. Rare variable decel. Moderate variability.

A/P:
Possible PROM: Mrs. X is a 33 yo G4P3003 at 25+1 weeks in no acute distress. No signs of PROM observed given absence of ferning, neg nitrazine test and AFI WNL. No signs/symptoms of PTL given history and tocometer. Though patient had vaginal wall tenderness on pelvic exam, KOH and wetprep unrevealing for evidence of candidal/BV infection and other suggestive symptoms absent.
- Discussed with patient to return to triage for vaginal bleeding, s/s of PTL, developing s/s of candidal infection or other new/concerning symptoms. Otherwise to follow up for ROB care. Patient indicates understanding and agrees with this plan.

