Case Study For Gynecological Health Assignment
Case Study For Gynecological Health Assignment
Case Study 5
Case Study: Obstetrics
Scenario 2
Phillipa Hudson is a 29-year-old female presenting today at your clinic with a positive home pregnancy test. Her medical history is negative. Surgical history negative. Gyn history 1st menses age 12, with cycles coming every 28 days and lasting for 5 days. Her pap and std history are negative. She has been taking a woman’s gummy vitamin for the past year. Her OB history is
Date gestation outcome gender wt. anesthesia complications
1-2011 6 TAB None
4-2014 39 Low forceps delivery male 8’14†epidural Gestational diabetes Case Study For Gynecological Health Assignment
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5-2016 8 weeks SAB
8-2016 35 weeks female. 7’1″. epidural. di/di twins
twins NSVD Female 6’6â€
7-2017 38 weeks SVD. male 8’10†local Gestational diabetes
Phillipa relates her last period (LMP) was 04-04-2022. She reports breast tenderness, fatigue, and nausea (which is what made her suspect she was pregnant).
****episodic visit, there is NOT to be a full PE. Focus on the systems that correlate to your Chief Complaint. ****
Most likely differential diagnosis are: Preeclampsia, gestational diabetes mellitus, and macrosomia
Gynecological Health
Patient Information:
- 29-year-old Caucasian female
CC (chief complaint): positive home pregnancy test
HPI:
Phillipa Hudson is a Caucasian female aged 29 years. She presents to the clinic complaining that he had a positive pregnancy test at home. According to her, her last menstruation was on 4th April 2022. She explains that she has been experiencing fatigue and breast tenderness. She also claims to feel nauseated most of the time, which led to her suspicion of being pregnant. Case Study For Gynecological Health Assignment
Current Medications: she is not taking any medications right now.
Allergies: she does not report any allergies to either medications or foods
PMHx: She has gestational diabetes twice. She has not had any surgical history. Her last tetanus vaccine was September 2021. She received a covid -19 vaccine in March 2021
Soc & Substance Hx: The patient is a 29-year-old woman, who is married to one man. She lives with her husband and children at their apartment, a few blocks from the shopping center. She likes reading books and travelling, but denies smoking and alcohol use. She admits putting on a seatbelt whenever driving. She further states that her house has operational smoke detectors. She walks to work every Tuesday and Thursday, and drives to work o Monday Wednesday and Friday. She occasionally works out at the gym, and states that her neighborhood is peaceful and no violence or crimes have been reported around.
Fam Hx: her mother was diagnosed with diabetes mellitus three years ago, while his father has history of hypercholesterolemia. No other significant history.
Surgical Hx: she denies having any surgeries.
Mental Hx: she denies previous diagnosis of any mental health related disorders
Violence Hx: she denies having any violent relationship, or being abused.
Reproductive Hx: Her first menstruation was at 12 years, and her last menstruation was on 4th of April 2022. She is gravida 5 and para 4. She has had two abortions, and a twin once. She is not breastfeeding presently, and does not mention using any type of a contraceptive. She is married and sexually active with one partner Case Study For Gynecological Health Assignment.
ROS:
GENERAL: she admits feeling generally tired, even after little activity. She denies fever or chills
HEENT: Eyes: no conjunctivitis, no blurred vision, discharge or sight loss. Ears, Nose, Throat: no Tinnitus, er discharge or ear pain reported. No nasal congestion, postnasal drainage, sinus inflammation, or runny nose., no swallowing difficulty, or sore throat.
SKIN: No tumors, abnormal pigmentation. No lesions.
CARDIOVASCULAR: No chest pain, chest pressure, or chest discomfort. No palpitations or edema.
RESPIRATORY: No labored respirations, shortness of breath, coughing or history of lung diseases.
GASTROINTESTINAL: Patient reports having nausea, but denies vomiting. No diarrhea, or constipation. She denies having hemorrhoids. No blood in stool, and denies abdominal pain.
NEUROLOGICAL: The patient reported occasional mild headaches, which go away on their own, when she relaxes. she denies seizures, and admits having one blackout spell I the previous two weeks. She denies having tingling or numbing of the extremities. She denies fecal or urine incontinence.
MUSCULOSKELETAL: No muscle pain, back pain, joint pain, or stiffness.
No joint pain or tenderness, swelling or erythema. She denies muscle and joint stiffness
HEMATOLOGIC: no bruising, no coagulopathy history, no anemia.
LYMPHATICS: demies history of splenectomy. She denies lymph node pain and tenderness.
PSYCHIATRIC: has no previous psychiatric history. She denies having depression or anxiety. She also denies having suicidal or homicidal ideations
ENDOCRINOLOGIC: she denies having temperature intolerance. She admits having elevated need to eat.
GENITOURINARY/REPRODUCTIVE: She denies having a burning sensation during urination, changes in frequency and urgency or urination. She denies having abnormal vaginal discharge. Her last menstruation was on 4th April 2022, and she is sexually active with one partner. She denies pain or bleeding after or during sexual activity. She admits having breast tenderness, but denies having lumps or nipple discharge.
ALLERGIES: She has no history relating to asthma, rhinitis, eczema or hives. She denies seasonal allergies too. Case Study For Gynecological Health Assignment
O.
Vital signs
BP: 115/82; Pulse: 85; RR: 18; Temp: 98.7F;
Height: 5’6” Weight: 150lbs BMI: 20
ABDOMEN: inspection of the abdomen shows a darken linea nigra, and slight distension. Palpation reveals a firm mass, whose fundal height estimate is 12 weeks.
CARDIOVASCULAR: heart rate is regular, no evidence of a racing heartbeat. Capillary refill is 2 seconds, and S1 AND S2 are present and normal. There are no heart murmurs noticed on auscultation.
GENITOURINARY/REPRODUCTIVE: Her bladder Is non distended. vaginal discharge is clear, without odd smell. Vaginal examination shows a pinkish vagina and a closed cervix. Breast appear to be slightly enlarged, and palpation reveals tenderness. No dimpling or retractions noted. No lumps noted too.
MUSCULOSKELTAL: palpation of the extremities shows minimal edema. There is no evidence of hyperreflexia.
Diagnostic results:
- Blood test: since the patient had already done some test at home, it is important to verify those results using a blood test to ensure that the diagnosis of pregnancy is accurate. The results are positive for pregnancy
- A1C Test: to screen for diabetes- 5 2%,
A.
Primary and Differential Diagnoses
Primary diagnosis
Pregnancy: the patient present with signs that accompany pregnancy, including breast tenderness and nausea, that is often followed by vomiting (Fowler, et al., 2022)Case Study For Gynecological Health Assignment. In addition, the patient had conducted a home test that turned to be positive for pregnancy. In many cases, pregnant mothers tend to have physiological edema, and increased need for food than before.as observed in this patient.
Differential diagnosis:
Pre-eclampsia: pre-eclampsia is defined as increased blood pressures during pregnancy (Karrar, & Hong, 2022). This is suspected based on the report that the patient is experiencing occasional headaches as well as edema of the feet. However, it is ruled out since the blood pressures are seen to be withing normal ranges (115/82).
Gestational diabetes: the patient reports that she has been experiencing increased hunger and the urge to eat. She also states that she had had gestational diabetes twice, this might be a probable diagnosis. The A1C test result are 5.02%, negative and non-conclusive for diabetes, so this diagnosis is eliminated
Acute fatty liver of pregnancy: it is an uncommon condition that is characterized by anorexia, nausea and vomiting. Additionally, patients may manifest with fatigue headaches and abdominal pain. However, the diagnosis is eliminated since patient with this disorder often present with jaundice, and abdominal pain (Hady, & Kupec, 2021) which is absent in the patient.
Since the patient is confirmed to be pregnant, she is advised to take iron and folic acid tablets, to prevent fetal malformations, and related complications (Fowler, et al., 2022)Case Study For Gynecological Health Assignment. Since she reports mild nausea that does not progress to vomiting, the patient is advised to take water occasionally, to prevent vomiting and alleviate nausea and headache. Patient is advised to eat a balanced diet, in small amount several times too, to prevent nausea. The patient is also advised to be active, and observe for signs of diabetes, since he has a history of gestational diabetes. In addition, she also educated to observe sign of abortion, since she also has also history of abortions
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References
Fowler, J. R., Mahdy, H., & Jack, B. W. (2022, April 21). Pregnancy – StatPearls – NCBI bookshelf. National Center for Biotechnology Information. https://www.ncbi.nlm.nih.gov/books/NBK448166/
Hady, Y., & Kupec, J. (2021, July 10). Fatty liver in pregnancy – StatPearls – NCBI bookshelf. National Center for Biotechnology Information. https://www.ncbi.nlm.nih.gov/books/NBK545315/
Karrar, S. A., & Hong, P. L. (2022, March 26). Preeclampsia – StatPearls – NCBI bookshelf. National Center for Biotechnology Information. https://www.ncbi.nlm.nih.gov/books/NBK570611/ Case Study For Gynecological Health Assignment