Responses weeko 8
briala
Responsesweeko8.docxResponse 1
Patient Information: P.H., 29, Female,
CC (chief complaint): “suspects she is pregnant.”
HPI: P.H. Is a 29-year-old female who presents to the clinic with a positive home pregnancy test. She reports breast tenderness, fatigue, and nausea. She stated her last period was 12-10-2021. G5T3P2A2L4. Medical history is negative. Surgical history is negative.
Current Medications: takes a woman’s gummy’s vitamin for the past year.
Allergies: No information available
PMHx: No information available
Soc & Substance Hx: No information available
Fam Hx: No information available
Surgical Hx: no surgical history
Mental Hx: medical history negative
Violence Hx: No information available
Reproductive Hx: She had her first menses age 12, with cycles coming every 28 days and lasting 5 days. Her last period was 12-20-2021. Her pap and std history are negative. She has had two abortions (one therapeutic and one spontaneous) at 6weeks and 8ths. Has had three full term pregnancies resulting in four live births and all were spontaneous vaginal delivery. Two of the deliveries were with epidural and one was local. With the 3 FT pregnancies, she had gestational diabetes.
ROS: No information available
HEENT: No information available
CARDIOVASCULAR: No information available
RESPIRATORY: No information available
GASTROINTESTINAL: No information available
NEUROLOGICAL: No information available
MUSCULOSKELETAL: No information available
HEMATOLOGIC: No information available
LYMPHATICS: No information available
PSYCHIATRIC: No information available
ENDOCRINOLOGIC: No information available
GENITOURINARY/REPRODUCTIVE: She had her first menses age 12, with cycles coming every 28 days and lasting 5 days. Her last period was 12-20-2021. Her pap and std history are negative. She has had two abortions (one therapeutic and one spontaneous) at 6weeks and 8ths. Has had three full term pregnancies resulting in four live births and all were spontaneous vaginal delivery. Two of the deliveries were with epidural and one was local. With the 3 FT pregnancies, she had gestational diabetes.
Allergies: No information available
Physical exam: No information available
Diagnostic results:
—Urine pregnancy test (Urine hCG) to determine if pregnant. On initial presentation, pregnancy can be confirmed through beta-human chorionic gonadotropin (beta-HCG) testing of the urine (Anderson& Ghaffarian, 2023).
—urinalysis with culture if indicated— would also check for protein and ketones in her urine due to history of gestational diabetes. Also, evaluate for bacteria in the urine for possible pyelonephritis.
--Urine drug screen—this is to determine if the patient has any drugs are in her system and if so, treat accordingly.
Once pregnancy is determined, we will do a Prenatal panel which consists of:
CBC —complete blood count
Hemoglobin A1C— to determine her current A1C for monitoring due to her history of gestational diabetes.
CMP—comprehensive metabolic panel — to determine the functioning of the liver, kidneys, as well as blood sugars and blood protein.
Blood typing including Rh screen.
Rubella viral antigen screen to determine if the patient is immune to the rubella disease.
STI panel— Screening for sexually transmitted infections in our patient.
—Ultrasound to determine a due date. In early pregnancy, ultrasound's main use is to determine the presence of an intrauterine pregnancy (Anderson& Ghaffarian, 2023).
--Fetal Heart tones – due to the patient’s last cycle was 12/10/2021 and if the pregnancy is confirmed, we would check for fetal heart tones. The heart rate (HR) increases between the fifth week of gestation and ninth week of gestation and after the 13th week of gestation reduces (Valenti, Di Prima, Renda, Faraci, Hyseni, De Domenico, Monte, & Giorgio, 2011).
A.
Primary and Differential Diagnoses:
Primary diagnosis: Z32.0 Encounter for pregnancy test, results unknown— This would be the primary diagnosis since the patient has had a positive home pregnancy test and has the symptoms of pregnancy, but the positive pregnancy has not been confirmed through diagnostic testing. Patient does have the presumptive symptoms of nausea, breast tenderness and fatigue but the pregnancy is not confirmed until we have clinical positive urine test as well as fetal heart tones and positive ultrasound of the fetus. Therefore, this is the most primary diagnosis.
Differential diagnosis:
O09.899–High risk pregnancy, Unspecified trimester—This would be a possible differential diagnosis due to the patient has had a positive home pregnancy test, but it has not been confirmed. And because of the circumstances surrounding her previous pregnancies and delivery, she would be considered elevated risk. At this point, her pregnancy has not been confirmed through diagnostic measures and therefore, we do not know what trimester, if any, she is in.
Z32.01—Encounter with pregnancy test, results positive—This would be a possible differential diagnosis because she had a positive home pregnancy test but it has not been confirmed by clinical diagnostic tools. To use this diagnosis, the pregnancy test would have to be confirmed positive.
Z87.59–Personal history of other complications of pregnancy, childbirth—This would be a possible differential diagnosis due to the patient’s history of complications of previous pregnancies. This would not be the primary diagnosis because the pregnancy cannot be confirmed.
Prescribed:
Prenatal vitamin one by mouth each morning.
Zofran 4mg ODT by mouth every 6hours as needed for nausea and vomiting.
—Encourage to take a prenatal vitamin every morning.
--For nausea and vomiting, take the Zofran as needed. Drink plenty of liquids and eat small portions of bland foods. Use the BRAT diet which consists of foods such as bananas, rice, applesauce, and toast until the nausea subsides (Jin,2017).
—Encourage to eat a diet rich in vitamins and mineral with a focus on calcium and folic acid. During pregnancy you need folic acid, iron, calcium, vitamin D, choline, omega-3 fatty acids, B vitamins, and vitamin C which can be found in foods such as dark green leafy vegetables, orange juice, beans, breads, pastas, and cereals (ACOG, 2021)
—Due to history of gestational diabetes, encourage patient to start keeping a food diary and limiting carbohydrates/starches and sugars in her diet. Educate her on symptoms of diabetes as well as hyper/hypoglycemic symptoms and what to do in the event they occur.
—Next follow up appointment in 4 weeks.
—Educate the patient on the signs and symptoms of preterm labor or problematic symptoms.
Health maintenance:
—Encourage patient to make a dental checkup every 6months. Pregnancy can deplete essential vitamins and minerals in your body which can lead to tooth decay and other issues.
--Encourage patient to get some exercise in daily. This is to include minimal impact workouts such as walking or swimming.
--Encourage patient to drink lots of water. This is important to keep patient hydrated as well as child.
Response 2
Patient Information:
P.H, 29y/o, Female
S.
CC: presents to the clinic with a positive home pregnancy test.
HPI: P.H is a 29 y/o female that presented to the clinic today with a positive home pregnancy test. P.H has also been experiencing breast tenderness, fatigue and nausea, which is what made her suspect she was pregnant. Denies any other complaints today. P.H states LMP was 12/10/2021.
Current Medications: OTC Women’s Gummy Vitamin since last year.
Allergies: NKDA
PMHx: Gestation Diabetes with 2nd and 5th pregnancy.
Soc & Substance Hx:
Fam Hx:
Surgical Hx: Prior surgical procedures.
Mental Hx:
Violence Hx:
Reproductive Hx: Onset of menses at age 12 y/o. Menstrual cycle every 28 days, lasting 5 days. Pap and STD history is negative. LMP 12/10/2021. G5 P2 1 2 4.
OB Hx:
1/2011 G.A 6 wks TAB. no complications
4/2014 G.A 39 wks. low forceps delivery, male, wt 8’14”, anesthesia: epidural. Complications: GDM
5/2016 G.A 8 wks. SAB.
8/2016 G.A 35 wks. NSVD twins. Female/female. Wt. 6’6”, 7’1”. Anesthesia: epidural. Complications: Di/di twins
7/2017 G.A 38 wks. SVD. Male. Wt 8’10”. Anesthesia: local. Complications: GDM.
ROS:
GENERAL: + nausea, fatigue and breast tenderness.
GASTROINTESTINAL: + nausea
GENITOURINARY/REPRODUCTIVE: + home pregnancy test. G6 T2 1 2 4 LMP: 12/10/2021. + Breast tenderness.
O.
Will need to obtain vital signs, current weight, height, BMI. Perform focused bimanual pelvic examination, clinical breast examination. Gastrointestinal examination. Obtain date of last Pap/Std panel
Diagnostic results: Will need urine hcg, BPE, Pap if not done within three years. Transvaginal ultrasound. Obtain initial prenatal labs.
A .
DDX#1. Primary Diagnoses: High-risk Pregnancy. O09.891. I selected this as the primary, most important diagnosis due to the potential health risks associated with high risks pregnancies, and due to this patient’s health history for GDM with two pregnancies, macrosomia, and prior spontaneous abortion. The term “high-risk pregnancy” is used to describe a situation in which a mother, her fetus, or both are at higher risk for problems during pregnancy or delivery than in a typical pregnancy. A high-risk pregnancy may be one that involves chronic health problems, such as diabetes or high blood pressure; infections; prior miscarriages; complications from a previous pregnancy; or other issues that might arise during pregnancy (National Institute of Health, 2018). Gestational diabetes can cause problems for both mother and fetus, including preterm labor and delivery, and high blood pressure. Close monitoring by healthcare professionals is paramount to minimize the risks to the mother and fetus (Anderson & Ghaffarian, 2023).
DDX#2. Gestational Diabetes. O24.41. I based this condition as a differential diagnosis due to her prior history of GDM with two of her pregnancies. The definition of gestational diabetes mellitus (GDM) is any degree of glucose intolerance with onset or first recognition during pregnancy (Quintanilla Rodriguez & Mahdy,2022). Gestational diabetes occurs when a woman who didn’t have diabetes before develops diabetes when she is pregnant. Gestational diabetes can cause problems for both mother and fetus, including preterm labor and delivery, and high blood pressure. It also increases the risk that a woman and her baby will develop type 2 diabetes later in life (National Institutes of Health, 2018). Gestational diabetes is a disease developed during the second and third trimester of pregnancy, characterized by a marked insulin resistance secondary to placental hormonal release (Quintanilla Rodriguez & Mahdy, 2022). Women diagnosed with GDM typically deliver larger babies, macrosomia, due to maternal high glucose levels during pregnancy. Maternal high glucose levels cross the placenta and produce fetal hyperglycemia. The fetal pancreas gets stimulated in response to the hyperglycemia. Insulin anabolic properties induce fetal tissues to growth at an increased rate (Quintanilla Rodriguez & Mahdy, 2022).
DDX#3. Early Pregnancy. Z34.91. I selected this as A differential diagnoses due to her reported positive home pregnancy test and symptoms of breast tenderness, fatigue and nausea. P.H. is a 29 y/o female, G5 T2 1 2 4, with a history of regular menstrual cycles every 28 days, with 5-day duration with LMP 12/10/2021. Pregnancy-related physical symptoms are common in the first trimester, with nausea reported by approximately 80% of women (Lutterodt et al, 2019). Additional information would need to be obtained to confirm this presumptive diagnosis including sexual history, contraception usage, urine hcg, serum hcg, pelvic examination and transvaginal ultrasound. Indications for obtaining a pregnancy test, urine or serum, include a female of child-bearing age with any of the following symptoms: amenorrhea/dysmenorrhea, abdominal/pelvic pain, nausea, vomiting, vaginal discharge, urinary symptoms, dizziness/lightheadedness/syncope, hypotension, or tachycardia (Anderson & Ghaffarian, 2023).
1.
Diagnostic Studies Ordered:
Urine HCG. Human chorionic gonadotropin (hCG) is a chemical created by trophoblast tissue, typically found in early embryos and which will eventually be part of the placenta. Measuring hCG levels can be helpful in identifying a normal pregnancy, pathologic pregnancy, and can also be useful following an aborted pregnancy (Betz & Fane, 2022). The hormone itself is a glycoprotein composed of two subunits, the alpha and beta subunits (Betz & Fane, 2022). There are multiple forms found in the serum and urine during pregnancy including the intact hormone and each of the free subunits (Betz & Fane, 2022). HCG is primarily catabolized by the liver, although about 20% is excreted in the urine (Betz & Fane, 2022). The beta subunit is degraded in the kidney to make a core fragment which is measured by urine hCG tests (Betz & Fane, 2022). Levels of hCG in a viable intrauterine pregnancy double approximately every 48 hours in early pregnancy (Pascual & Langaker, 2022). Levels peak around 10 to 12 weeks gestation, then decline to a steady state after 15 weeks (Pascual & Langaker, 2022).
Naegele’s Rule: Establish the date of the last menstrual period by obtaining a history from the patient. From this date, add 1 year and 7 days, then subtract 3 months (Naidu & Fredlund, 2022). This will approximate the estimated delivery date. The date of the last known menstrual period will give the approximate start date for age of the fetus (Naidu & Fredlund, 2022).
Non-Sonographic Methods for Determining Gestational Age, Bimanual Pelvic Exam: Bimanual pelvic examination is important to do to assess for possible other causes or conditions that may be related to the patients complaints. Assessing for signs of infections, such as cervical discharge, odors, cervical wall tenderness, will help to rule out abnormalities. The uterus has been described as a soft and globular pelvic organ. In pregnancy, the uterus increases in size to accommodate the developing fetus (Naidu & Fredlund, 2022). At approximately 12 weeks gestation the uterus becomes large enough to be palpable just above the pubic symphysis (Naidu & Fredlund, 2022). At 16 weeks gestation, the fundus of the uterus can be palpated at the midpoint between the umbilicus and the pubic symphysis (Naidu & Fredlund, 2022). At 20 weeks gestation, the fundus can be palpable at the level of the umbilicus. After 20 weeks of gestation, the pubic symphysis to fundal height in centimeters should correlate with the week of gestation (Naidu & Fredlund, 2022).
Pap Smear: if last Pap was > 3 years ago. HPV
Transvaginal Ultrasound: First Trimester Dating: Ultrasound confirmation of early pregnancy is utilized when an individual has a positive pregnancy test along with pelvic pain, abdominal pain, or vaginal bleeding (Pascual & Langaker, 2022). Confirmation of a viable pregnancy occurs with an ultrasound, which shows a gestational sac on transvaginal ultrasound at five weeks or with an hCG level of 1,500 to 2,000 mIU/mL. Fetal heart motion is visible on transvaginal ultrasound at six weeks or with hCG levels starting at 5,000 to 6,000 mIU/mL (Pascual & Langaker, 2022). Additionally, ultrasound can be used to evaluate for the presence of an ectopic pregnancy (cornual, tubal, adnexal, cervical, abdominal, cesarean section ectopic), free fluid in the pelvis, uterine and adnexal pathology, fetal cardiac activity and heart rate, miscarriage, or gestational trophoblastic disease (Anderson & Ghaffarian, 2023). Two anatomical approaches are used to visualize a pregnancy using ultrasound; transvaginal and transabdominal. A transvaginal ultrasound is performed using a high-frequency endocavitary probe placed into the vagina and visualizing the pelvic organs through the cervix (Anderson & Ghaffarian, 2023). In contrast, a transabdominal ultrasound uses a lower frequency sound wave that can also be used to visualize pelvic organs but does so by looking through the abdominal wall with a curvilinear probe (Anderson & Ghaffarian, 2023). The difference in frequency, along with the probe's anatomical placement during the exam, results in the transvaginal approach being superior for visualizing a very earlier pregnancy as well as evaluating the adnexa (Anderson & Ghaffarian, 2023). Sonographic assessment within the first 13 weeks and 6 days will provide the most accurate estimate of gestational age (Naidu & Fredlund, 2022). Both transvaginal and transabdominal approaches may be used (Naidu & Fredlund, 2022). However, the transvaginal approach may provide a more clear and accurate view of early embryonic structures (Naidu & Fredlund, 2022). Although the gestational sac and yolk sac are the first measurable markers visible on ultrasound, these poorly correlate with gestational age (Naidu & Fredlund, 2022). The crown-rump length (CRL) is the most accurate measurement correlating with gestational age (Naidu & Fredlund, 2022). Using the mean of three measurements, CRL can be determined by using the calipers on the ultrasound machine, measuring a straight line from the outer margin of the cephalic pole to the rump of the embryo. This measurement can be plugged into numerous validated tables and formulas that correlate well with gestational age (Naidu & Fredlund, 2022).
Fasting Blood Sugar. This will provide baseline to assess need for diabetes given her history of GDM she is at higher risk.
Hgb A1c. to assess diabetes, prediabetes.
Labs to be obtained at 9-14 weeks. Initial prenatal profile: ABO Rh, CBC, HIV, RPR (w/reflex to Treponema), Hep C, Hep B, UA, C&S, Rubella, Lead, Quantiferon TB Gold, Inheritest Society Guided panel, MaterniT21, early 1-hour GTT test (to be done at 20-24wks, normally done at 28 wks), due to hx of GDM.
PREGNANCY - STI Screening Recommendations from the CDC 2021 Guidelines: Sexually transmitted infections can seriously complicate pregnancy and potentially cause serious health consequences for the mother and her unborn child (Garcia et al, 2022). Therefore, the CDC currently recommends the following routine STI screenings in pregnancy: First Prenatal Visit: All pregnant women should be tested for HIV, Hepatitis B, Hepatitis C, and syphilis at their first prenatal visit (Garcia et al, 2022).
EPDS Screening
Patient Education:
Follow heart healthy diet, limit/avoid high carbohydrate, high sugar food/drinks. Avoid any alcohol containing drinks! Do not smoke, vape or use any recreational drugs as these may harm the fetus and lead to severe health issues.
For Nausea: Eat small meals/snacks three times per day. Dry toast or crackers in the morning before you get out of bed to avoid moving around on an empty stomach.
Eat five or six “mini meals” a day to ensure that your stomach is never empty.
Eat frequent bites of foods like nuts, fruits, or crackers.
Avoid fried foods, spicy foods, and other foods that cause you to feel nauseated. The smell of some foods may make you feel nauseated. Avoid these foods, especially when they are being cooked.
Management of Breast Tenderness:
Wear a more supportive bra.
Create a "no touch" zone.
Opt for loose-fitting clothes.
Try a cold compress.
Take warm showers.
Avoid use of NSAID’s. Increased risks of miscarriage and malformations are associated with NSAID use in early pregnancy. Conversely, exposure to NSAIDs after 30 weeks' gestation is associated with an increased risk of premature closure of the fetal ductus arteriosus and oligohydramnios (Antonucci et al, 2018).
For Fatigue: Rest when ever possible. Ensure you are eating and drinking to help nourish your body as it is going through changes. Try to get 8+ hours of sleep at night.
Medications:
Begin Prenatal vitamins with folic acid supplementation
Referral: High Risk Obstetrician.
