Case Study For Obstetrics Assignment Discussion
Case Study For Obstetrics Assignment Discussion
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
5-2016 8 weeks SAB
8-2016 35 weekstwins NSVD FemaleFemale 6’6â€7’1†epidural Di/di twins
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).
Differential diagnosis (dx) with a minimum of 3 possible conditions or diseases.
Define what you believe is the most important diagnosis. Be sure to include the first priority in conducting your assessment.
Explain which diagnostic tests and treatment options you would recommend for your patient and explain your reasoning.
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Patient information
Patient initials: P.H Age: 29 Gender: Female Race: not mentioned
Subjective
CC: “Breast tenderness, nausea, and fatigue.”
HPI: P.H, a 29-year-old female, presented to the clinic unaccompanied with the chief complaint of nausea, fatigue, and breast tenderness, which she claimed prompted her to suspect she was pregnant. She also reported taking home pregnancy tests which came out positive. The patient stated that she has been taking Woman’s Gummy for the past year. She denies any other complaints.
Current medication: Women’s gummy one tab PO QD
PMH: gestational diabetes during her 2nd and fifth pregnancy
Allergy: NKDFA
Family history: no significant family history was reported.
Social history: denies tobacco smoking and alcohol consumption. Case Study For Obstetrics Assignment Discussion
OB Hx: G6T2P2A2L4
Gyn Hx: began menses at 12-year-old. It follows a 28-day-cycle that lasts five days. LMP 4/4/22. Denies history of STDs.
ROS
General: Denies fever, chills, and significant weight changes. Reported general fatigue
HEENT: Denies changes in vision or hearing.
Cardiovascular: Denies chest pain or irregular heartbeats, or heart murmurs
Respiratory: Denies SOB and chronic cough
GI: reported nausea. No anorexia reported
Skin: denies rashes or bruises
GU: Denies dysuria or polyuria
Msk: denies joint or muscle pain.
Neurologic: Denies dizziness and gait disturbances.
Hematological: denies bleeding
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PE
Vts.: T 37.3. Pulse ox: 94%. BP 130/66. P 72. R 20 Ht. 5’6 Wt.167lb
General: A&Ox3, with no acute distress. He is well-groomed.
HEENT; normocephalic. EOMI, PERRLA
Cardiovascular: RRR, S1, S2 sounds heard. No murmur nor gallops noted
MSK: muscle strength 5/5 bilaterally. A full range of motion was noted in all joints.
Skin: Warm and intact. Appropriate color for ethnicity.
Abdomen: Bowel sounds are normoactive. Non-tender
Breast: no masses, dimpling, or redness noted.
Genitalia: normal in appearance without tenderness. Cervix is non-tender without lesions. The uterus is anteflexed, mildly mobile, and non-tender. The ovary is non-tender with palpable masses.
Neuro: Memory and thought process intact. Stable gait
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Lab test and result
HCG pregnancy test: positive
Ultrasound to rule out an intrauterine pregnancy (IUP): result pending
Diagnoses
Early pregnancy
Based on the patient clinical presentation, including nausea, fatigue, breast tenderness, and her LMP, together with results of home pregnancy and laboratory test, it is likely that the patient is in her early pregnancy (Kazma et l.,2020)Case Study For Obstetrics Assignment Discussion.
Miscarriage
This is the natural death of an embryo that results mostly from an issue with hormones, genetic factors such as trisomy 18, and environmental factors such as exposure to a toxin (Quenby et al.,2021)Case Study For Obstetrics Assignment Discussion. It is a probable diagnosis owing to the patient report of having other previous abortions and complaint of nausea. Nevertheless, the patient clinical presentation, including breast tenderness, is not common in this condition.
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Ectopic pregnancy
This is also a likely diagnosis, but it is mostly characterized by abdominal pain and vaginal bleeding (Hendriks et al.,2020), which is not evident. Furthermore, the ultrasound result was positive for IUP.
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Additional lab tests: OB blood test to screen for any disease or infection that can interfere with pregnancy.
Medication: Based on the patient’s case scenario and lab test, I believe she is in her early pregnancy. Thus, I would recommend giving her prenatal vitamins to be taken PO QD throughout her pregnancy (Garcia-Serna et al.,2020)Case Study For Obstetrics Assignment Discussion.
Patient education: The patient must be educated on the need for a proper diet, relaxation, and hygiene. She must be taught about the risks of infection, including vaginal yeast infection, which is prevalent during pregnancy, and why they must be reported for treatment. For her safety, she must be encouraged to participate in varied exercises for at least 30 minutes.
Follow-up: the patient should return to the clinic after 28 days for further assessment.
References
Quenby, S., Gallos, I. D., Dhillon-Smith, R. K., Podesek, M., Stephenson, M. D., Fisher, J., … & Coomarasamy, A. (2021). Miscarriage matters: the epidemiological, physical, psychological, and economic costs of early pregnancy loss. The Lancet, 397(10285), 1658-1667.
Hendriks, E., Rosenberg, R., & Prine, L. (2020). Ectopic pregnancy: diagnosis and management. American family physician, 101(10), 599-606.
Kazma, J. M., van den Anker, J., Allegaert, K., Dallmann, A., & Ahmadzia, H. K. (2020). Anatomical and physiological alterations of pregnancy. Journal of pharmacokinetics and pharmacodynamics, 47(4), 271-285.
Garcia-Serna, A. M., & Morales, E. (2020). Neurodevelopmental effects of prenatal vitamin D in humans: systematic review and meta-analysis. Molecular psychiatry, 25(10), 2468-2481 Case Study For Obstetrics Assignment Discussion.
Episodic/Focused SOAP Note Template
Patient Information:
Initials, Age, Sex, Race
S.
CC (chief complaint): This is a brief statement identifying why the patient is here in the patient’s own words, for instance, “headache,” not “bad headache for 3 days.”
HPI: This is the symptom analysis section of your note. Thorough documentation in this section is essential for patient care, coding, and billing analysis. Paint a picture of what is wrong with the patient. Use LOCATES Mnemonic to complete your HPI. You need to start every HPI with age, race, and gender (e.g., 34-year-old African American female)Case Study For Obstetrics Assignment Discussion. You must include the seven attributes of each principal symptom in paragraph form, not a list. If the CC was “headache,” the LOCATES for the HPI might look like the following example:
Location: head
Onset: 3 days ago
Character: pounding, pressure around the eyes and temples
Associated signs and symptoms: nausea, vomiting, photophobia, phonophobia
Timing: after being on the computer all day at work
Exacerbating/relieving factors: light bothers eyes, Naproxen makes it tolerable but not completely better
Severity: 7/10 pain scale
Current Medications: Include dosage, frequency, length of time used, and reason for use. Also include over-the-counter (OTC) or homeopathic products.
Allergies: Include medication, food, and environmental allergies separately. Provide a description of what the allergy is (e.g., angioedema, anaphylaxis)Case Study For Obstetrics Assignment Discussion. This will help determine a true reaction versus intolerance.
PMHx: Include immunization status (note date of last tetanus for all adults), past major illnesses, and surgeries. Depending on the CC, more info is sometimes needed.
Soc & Substance Hx: Include occupation and major hobbies, family status, vaping, tobacco and alcohol use (previous and current use, how many times a day, how many years), and any other pertinent data. Always add some health promotion questions here, such as whether they use seat belts all the time or whether they have working smoke detectors in the house, the condition of the living environment, text/cell phone use while driving, and support systems available.
Fam Hx: Illnesses with possible genetic predisposition, contagious illnesses, or chronic illnesses. The reason for death of any deceased first-degree relatives should be included. Include parents, grandparents, siblings, and children. Include grandchildren if pertinent.
Surgical Hx: Prior surgical procedures.
Mental Hx: Diagnosis and treatment. Current concerns: (Anxiety and/or depression). History of self-harm practices and/or suicidal or homicidal ideation.
Violence Hx: Concern or issues about safety (personal, home, community, sexual—current and historical).
Reproductive Hx: Menstrual history (date of last menstrual period [LMP]), pregnant (gravida and Parity), nursing/lactating (yes or no), contraceptive use (method used), types of intercourse (oral, anal, vaginal, other), gender sexual preference, and any sexual concerns.
ROS: This covers all body systems that may help you include or rule out a differential diagnosis. You should list each system as follows: General: Head: EENT: and so forth. You should list these in bullet format and document the systems in order from head to toe Case Study For Obstetrics Assignment Discussion
Example of Complete ROS:
GENERAL: No weight loss, fever, chills, weakness, or fatigue.
HEENT: Eyes: No visual loss, blurred vision, double vision, or yellow sclerae. Ears, Nose, Throat: No hearing loss, sneezing, congestion, runny nose, or sore throat.
SKIN: No rash or itching.
CARDIOVASCULAR: No chest pain, chest pressure, or chest discomfort. No palpitations or edema.
RESPIRATORY: No shortness of breath, cough, or sputum.
GASTROINTESTINAL: No anorexia, nausea, vomiting, or diarrhea. No abdominal pain or blood.
NEUROLOGICAL: No headache, dizziness, syncope, paralysis, ataxia, numbness, or tingling in the extremities. No change in bowel or bladder control.
MUSCULOSKELETAL: No muscle pain, back pain, joint pain, or stiffness.
HEMATOLOGIC: No anemia, bleeding, or bruising.
LYMPHATICS: No enlarged nodes. No history of splenectomy.
PSYCHIATRIC: No history of depression or anxiety.
ENDOCRINOLOGIC: No reports of sweating or cold or heat intolerance. No polyuria or polydipsia.
GENITOURINARY/REPRODUCTIVE: Burning on urination. Pregnancy. LMP: MM/DD/YYYY. Breast-lumps, pain, discharge? No reports of vaginal discharge, pain?. sexually active?
ALLERGIES: No history of asthma, hives, eczema, or rhinitis.
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Physical exam: From head to toe, include what you see, hear, and feel when conducting your physical exam. You only need to examine the systems that are pertinent to the CC, HPI, and history. Do not use “WNL” or “normal.” You must describe what you see. Always document in head-to-toe format (i.e., General: Head: EENT:).
Diagnostic results: Include any labs, x-rays, or other diagnostics that are needed to develop the differential diagnoses (support with evidenced and guidelines)Case Study For Obstetrics Assignment Discussion.
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Primay and Differential Diagnoses (list a minimum of 3 differential diagnoses). Your primary or presumptive diagnosis should be at the top of the list. For each diagnosis, provide supportive documentation with evidence-based guidelines.
Includes documentation of diagnostic studies that will be obtained, referrals to other health care providers, therapeutic interventions, education, disposition of the patient, and any planned follow-up visits. Each diagnosis or condition documented in the assessment should be addressed in the plan. The details of the plan should follow an orderly manner. Also included in this section is the reflection. The student should reflect on this case and discuss whether or not they agree with their preceptor’s treatment of the patient and why or why not. What did they learn from this case? What would they do differently?
Also include in your reflection a discussion related to health promotion and disease prevention, taking into consideration patient factors (e.g., age, ethnic group), PMH, and other risk factors (e.g., socioeconomic, cultural background)Case Study For Obstetrics Assignment Discussion.
References
You are required to include at least three evidence-based, peer-reviewed journal articles or evidenced-based guidelines that relate to this case to support your diagnostics and differentials diagnoses. Be sure to use correct APA 7th edition formatting.
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
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| Date | gestation | outcome | gender | wt. | anesthesia | complications |
| 1-2011 | 6 | TAB | None | |||
| 4-2014 | 39 | Low forceps delivery | male | 8’14” | epidural | Gestational diabetes |
| 5-2016 | 8 weeks | SAB | ||||
| 8-2016 | 35 weeks
twins |
NSVD | Female
Female |
6’6”
7’1” |
epidural | Di/di twins |
| 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)Case Study For Obstetrics Assignment Discussion