Jessica Rivera

27 yo · 6 weeks postpartum · G2P2 (C-section) · Blood type O+

Allergies

Erythromycin — severe GI upset
Nickel — contact dermatitis

Active Problems

Postpartum, 6 wk post C-section — incision healed, cleared
GAD — pre-existing, worsened PP. Therapy (increasing to weekly). No meds
Edinburgh: 11 — mild-moderate range. Sertraline discussed, patient declines
Breast warmth/hardness — possible early mastitis, monitoring
Left nipple soreness — improving with latch correction
Hx gestational thrombocytopenia — resolved (128K → 215K)
Status post primary C-section (low transverse, breech)

Medications

Prenatal vitamin + DHA daily (breastfeeding)
Vitamin D3 1000 IU daily
Ibuprofen 400 mg PRN
Acetaminophen 500 mg PRN
Discussed, not started: Sertraline 25 mg (compatible with BF)

Key Labs

Edinburgh (6 wk): 11 (elevated, threshold ≥10)
Hgb (discharge): 10.8 g/dL (normal PP)
Platelets (discharge): 215 K (resolved)
Platelets (pre-op): 142 K (gestational thrombocytopenia)

Delivery Summary

Primary C-section at 39w0d for frank breech
Spinal anesthesia. Low transverse incision
Baby Sofia, 7 lb 2 oz, Apgar 8/9
EBL 750 mL (normal for C-section)
No opioids used — patient preference
Prior: SVD 38w2d (Lucia, now 2.5 yr)

Mental Health

GAD since 2023 (onset after 1st baby)
Therapy biweekly → increasing to weekly
No medication — patient preference
Edinburgh 11: difficulty sleeping, overwhelmed, crying more, anxious
Denies SI/HI. Denies anhedonia
Therapist: Amanda Chen, LCSW (telehealth)

Family History

Mother: GAD, gestational diabetes (with Jessica)
Maternal grandmother: T2DM, depression
Paternal grandmother: ovarian cancer (dx 63)
Sister: anxiety disorder

Social

Dental hygienist, maternity leave. Married
Two children: Lucia (2.5 yr), Sofia (6 wk)
Husband works FT (electrician, 7a–4p)
Mother visits 2–3x/wk. MIL monthly
Sleep 4–5 hrs, fragmented. Toddler also waking
Breastfeeding + occasional pumping. Lucia in part-time daycare

Recent Communications

02/24 — Patient portal: "My left breast feels warm and kind of hard on one side. Not red yet but sore, worse than normal breastfeeding soreness. Should I be worried about mastitis?"

02/25 — NP reply: Could be early mastitis or plugged duct. Warm compress before feeding, massage while nursing, nurse on that side first, ensure full emptying. If fever >100.4, worsening redness, flu-like symptoms — call immediately.

02/05 — Therapy note: Feeling "touched out" by end of day, snapping at toddler. Guilt about divided attention. Processing loss of autonomy. Increasing to weekly sessions.

Review Submitted