POST PARTUM for Vera and newborn visit for her infant Daniel

POST PARTUM for Vera and newborn visit for her infant Daniel seen… POST PARTUM for Vera and newborn visit for her infant Daniel seen in your primary care family practice. Chief Complaint 30-year-old G3P3003 female here for 6-week PP visit. She is currently breastfeeding and would like to discuss birth control options, preferably an IUD. LABS: Last pap WNL at first prenatal visit at 12 weeks. No history of abnormal PAPs Meds: Dicloxacillin 500mg q6h HPI: Date of delivery: 12/10/2021 at 41 2/7 wks; last pap smear: 2015 NSVD, male/Andrew, 7# 3oz, 2nd deg. Perineal lac, EBL=300. 8 hour labor, felt supported. Complications of pregnancy: gestational diabetes at 29 weeks, diet controlled. Complications of labor: none Postpartum complications: Mastitis diagnosed 5 days ago Feeding choice: breast and bottle; good support from partner/family Review of systems: no abnormal bleeding; no pelvic pain; no constipation; no fecal incontinence; no dysuria; no urinary incontinence; no fever Breastfeeding problems (baby was tongue tied-worked with ENT, frenulum clipped on day 7) . Has worked with LC at Peds provider. Currently pumping only after dx mastitis last week. On day 5 of dicloxacillin. Stopped nursing due to discomfort, recalls now lactation consultant said it would be okay to continue breastfeeding. Would like to try nursing again. Worried about decreased milk supply and return to work in 1 month.). Preferred birth control method: Mirena. No intercourse since delivery. Home: supportive father of the baby, 2 other siblings adjusting well. 1 in school, other preschool. Her mom is local and comes to help on Saturdays so she can go to gym and shop. No date night yet. Mental health: neg screen for depression Vitals: Wt: 164.2 Ht: 5Ft 6in BMI: 26.5 B/P: 102/64, 78. Physical Exam: Constitutional: General: well-appearing, Cardiovascular: RRR and no murmur. Peripheral Vascular: no varicosities or edema. Lungs: Respiratory Effort: no accessory muscle usage or intercostal retractions. No wheezing, rales/crackles, or rhonchi and clear to auscultation. Breast: Breastfeeding. Symmetric. No nipple trauma noted, everted. No breast erythema, skin changes or dimpling bilaterally. Nontender, dense fibroglandular, no dominant mass. Post nursing, nipple round, everted. Abdomen: Inspection/Palpation: slightly round, no tenderness, hepatomegaly, or splenomegaly, soft. Hernia: none. Female Genitalia: Mons: no erythema, excoriation, atrophy, lesions, masses, swelling, tenderness, or vesicles/ ulcers and normal. Labia Majora: no erythema, excoriation, discoloration, lesions, masses, swelling, tenderness, or vesicles/ ulcers and normal. Labia Minora: no erythema, excoriation, discoloration, lesions, vesicles, masses, swelling, or tenderness. Has normal BF atrophy. Introitus: laceration well healed. Bartholin’s Gland: normal. Vagina: no discharge, erythema, atrophy, lesions, ulcers, swelling, masses, tenderness, prolapse, or blood present and normal. Cervix: parous, no lesions, discharge, bleeding, or cervical motion tenderness and grossly normal. Uterus: normal size/small and midline, mobile, non-tender, and no uterine prolapse. Urethral Meatus/ Urethra: no discharge, masses, or tenderness and normal meatus and well supported urethra. Bladder: non-distended, non-tender, and no palpable mass. Adnexa/Parametria: no tenderness or mass palpable. Rectum: Anus & Perineum: normal perineum and perianal skin and no hemorrhoids or anal fissure. Extremities: Tibia: no edema. Homan’s neg. Neurological System: Impressions motor: no deficits and sensory: no deficits. Psychiatric: Mood and Affect: normal mood and affect. Adjusting well to new baby. EPDS: 4/30 Newborn exam: Bright eyed, alert during first half of visit, nursed during visit, then sleepy. HEENT: bright, slight nystagmus, milia on nose. head round, anterior fontanel flat/soft, 4 cm dry, non-erythematous patch on posterior head c/w cradle cap. Mouth: upper lip-small sucking blister. Strong suck on gloved finger. Good wide mouth for nursing, tongue movement appropriate, frenulum not tight post clipping, good swallow sounds, no thrush, football hold by mom without difficulty.  1) What are the diagnoses for Vera including the ICD-10 codesHealth Science Science Nursing NURSING MISC

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