34 year old,White,female

Delivered 3rd childyesterday spontaneous

vaginal delivery

Male,weight=3.8 kg,height =50cm

Pregnancy full term,No complications

Mother and childprogressing well

sinus pressure increases when lying

down at night

dull sinus pressure just under

her cheekbones describes as “mild-not that

bad really’

small amount of clear nasal discharge

catches a cold 2-3 times a year which “often

cause pressure in my sinuses”

has never experienced nosebleeds

“small amount” of red lochia

experiencing only “mild”

post-partum pains

perineum is “slightly tender”

breasts feel “full but soft”

applies a perineal cold pack

every 4-6 hours

plans to breast-feed

discontinued smoking during both of her

previous pregnancies, but returned smoking

within 6 months post-partum each time

has not smoked since finding out

she was pregnant

Prior to pregnancysmoked 1 pack

per day (X18 years),

moderate flow lasting 3-4 days

periods are regular every 28-30 days

began menstruating at age 12

presently weight 62kg (136pounds).

gained 16kg (35pounds)

during pregnancy

the last couple of weeks found it difficult to obtain a sound sleep because

she “just could not find a comfortable position” and

had a “bit of a cold” generally a good sleeper (7-8hours a night)

has a soft-formed brown BM’s

every 1-2 days eats well

does not consume alcoholic beverages

Recently noted her hair texture is ather “coarse”

recently noted that her scalp has been

drier than usual

no known allergies

no skin problems

No major health problems

She napped throughout the day, but still feels tired. However, there is no

impairment in performance of ADL

Last night she was awake twice during the night because

she was caring for her baby

168 cm tall

No chest or leg pain

rarely has a headache. Headaches in the past

have always been relieved with Tylenol

does not remember ever having an ear

infection or earaches

no hearing problems

She sees well with glasses for myopia

visits the ophthalmologist every 2 years

does not take any medications

Takes 1 iron pill daily

There has been no hair loss

Eats meat, fish or chicken twice a day

always eats 6 to 7 fruits or vegetables

a day

doesn’t skip meals

She wears a partial upper denture, which

she soaks each night in Polident No chest or leg pain

She always wears a seat belt

has never experienced dizziness,

vertigo, or syncope

does not have varicose veins or problems

with circulation, leg infection or ulcers

All immediate family members are healthy

lives with her husband and 2 children (Ronda aged 8

and John aged 4). She enjoys cooking

and rarelyeats out

She now eats approximately 10 servings of grain

products per day

eats whole grain cereals to suppress

her appetite

makes sure that she drinks more milk

(around 4 glasses/day)

Since delivery, she has a

“ravenous appetite

drinks 2-3 cups/ glasses of juice or tea a day

but doesn’t like water

Their home is a single family dwelling in a safe neighbourhood

her relationship with her husband (aged 42) is “very close” with no marital problems

Her husband manages

a large businesshas been a stay-at-home

mother since birth of her second child

graduated high school, and completed an Early Childhood

Educator’s diploma

they are financially secure

Both paternal grandparents died at the age of 76 from complications

related to IDDM

she has one sister (age 38) who has a

history of NIDDM

Her father is 60 years old and

has hypertension

Her mother is 56 years old has

no medical problems

Her parents live within walking

distance

She hopes to remain a

non-smoker for life

She says that she was “pretty stressed” last year upon

the sudden death of a close friend. She found that talking to her husband,

parents, and her faith/ prayer helped her get through this

episode in her life

She feels good about herself

She takes pride in her role as a

mother and housewife

she had an appendectomy at

age 12

she has had the usual childhood illnesses

like chicken pox, measles and Mumps

her immunizations are up to date

Ms Reid