Complaining of two months of amenorrhea

 

 

Tonia is an 18-year-old female who presents to your office complaining of two months of amenorrhea. Her pregnancy test is positive and her LMP indicates she is 5.6 weeks EGA. She reports she has had some bleeding for the past 3 days, that started as spotting but has continued to be a light period- like bleeding today. She denies any pain. She indicates plans to continue the pregnancy.
Please include questions and patients answer
1. Subjective:
a. What other relevant questions should you ask regarding the HPI?
b. What other medical history questions should you ask?
c. What other social history questions should you ask?
2. Objective:
a. Describe all elements of the head-to-toe assessment you will perform for her initial prenatal visit
b. Explain what test(s) you will order and perform and discuss your rationale for ordering and performing each test.
3. Assessment/ Diagnosis:
a. What are your presumptive and differential diagnoses, and why?
b. Any other diagnosis or differential diagnosis you would like to add?
c. Assume you ordered an HCG today and the result was 1200. She returns to the clinic in 2 days and her HCG results is 550. What would be her diagnosis?
4. Plan:
a. How will you explain the HCG results to your patient?
b. Explain treatment guidelines and side effects including any possible side effects of the medication and treatment(s), partner notification, and follow-up plan of care.
c. What patient education is important to include for this patient? (Consider when can the patient resume sexual activity, birth control options, when she can resume trying to conceive again).
Provide evidence from the research to support your decision-making.

Sample Solution

Subjective

HPI Questions:

  • Bleeding: How heavy is the bleeding? Is it bright red or dark brown? Are there any clots?
  • Cramps or Pain: Are you experiencing any cramping or pain in your abdomen or back?
  • Nausea and Vomiting: Are you experiencing any nausea or vomiting?
  • Urinary Symptoms: Any changes in urination, such as frequency or burning?
  • Vaginal Discharge: Any unusual vaginal discharge, such as color, odor, or amount?

Medical History:

  • Previous pregnancies: Any previous pregnancies, miscarriages, or abortions?
  • Chronic medical conditions: Diabetes, hypertension, thyroid disorders, or other medical conditions?
  • Surgical history: Any previous surgeries, especially gynecological procedures?
  • Family medical history: Any family history of genetic disorders, birth defects, or pregnancy complications?

Social History:

  • Lifestyle factors: Smoking, alcohol use, or drug use?
  • Occupational hazards: Exposure to any harmful substances or radiation?
  • Support system: Do you have a partner or support system in place?
  • Insurance coverage: Do you have health insurance?

Objective

Head-to-Toe Assessment:

  • General Appearance: Assess overall appearance, level of distress, and vital signs (blood pressure, heart rate, respiratory rate, temperature).
  • Abdominal Exam: Palpate the abdomen for tenderness, uterine size, and adnexal masses.
  • Pelvic Exam: Perform a pelvic exam to assess cervical length, cervical consistency, and any signs of bleeding or infection.
  • Speculum Exam: Visualize the cervix and vagina for any abnormalities.

Diagnostic Tests:

  • Urine Pregnancy Test: Confirm pregnancy and assess hCG levels.
  • Transvaginal Ultrasound: To visualize the gestational sac, fetal pole, and fetal heart activity.
  • Blood Tests: Complete blood count (CBC), blood type, Rh factor, and rubella titer.

Assessment/Diagnosis

Presumptive Diagnosis: Early pregnancy with threatened abortion.

Differential Diagnoses:

  • Ectopic Pregnancy: Consider if the patient presents with severe abdominal pain or vaginal bleeding.
  • Molar Pregnancy: If there is rapid rise in hCG levels or unusual ultrasound findings.

HCG Levels:

  • Rising HCG: Indicates a viable pregnancy.
  • Decreasing HCG: Suggests a potential miscarriage.

Plan

Explaining HCG Results:

  • Rising HCG: Explain that the rising hCG level is a positive sign of a healthy pregnancy.
  • Decreasing HCG: If the HCG level is decreasing, discuss the possibility of a miscarriage and provide emotional support.

Treatment and Follow-Up:

  • Bed Rest: Advise the patient to rest and avoid strenuous activity.
  • Pelvic Rest: Avoid sexual intercourse and tampon use.
  • Follow-up: Schedule a follow-up ultrasound to assess fetal viability and growth.
  • Medication: If bleeding is heavy, medication may be prescribed to reduce bleeding.

Patient Education:

  • Signs of Complications: Educate the patient on signs of potential complications, such as severe abdominal pain, heavy bleeding, or fever.
  • Prenatal Care: Emphasize the importance of regular prenatal care, including prenatal vitamins, healthy diet, and avoiding harmful substances.
  • Sexual Activity: Advise the patient to avoid sexual intercourse until the bleeding stops and cleared by her healthcare provider.
  • Birth Control: Discuss future birth control options and family planning.

By providing comprehensive care, including physical examination, diagnostic tests, and patient education, healthcare providers can help patients navigate early pregnancy and minimize complications.

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