enario A normal ongoing pregnancy, the expectation for the beta HCG level is to 35% (hint: increase by how much) within 48-72 hours (Grunbaum, 2021).
Scenario
A normal ongoing pregnancy, the expectation for the beta HCG level is to 35% (hint: increase by how much) within 48-72 hours (Grunbaum, 2021).
Scenario
A normal ongoing pregnancy, the expectation for the beta HCG level is to 35% (hint: increase by how much) within 48-72 hours (Grunbaum, 2021).
Scenario
A normal ongoing pregnancy, the expectation for the beta HCG level is to 35% (hint: increase by how much) within 48-72 hours (Grunbaum, 2021).
Scenario
A normal ongoing pregnancy, the expectation for the beta HCG level is to 35% (hint: increase by how much) within 48-72 hours (Grunbaum, 2021).
During a spontaneous abortion (miscarriage), the expectation for the beta HCG level is to 49% (hint: decrease by how much) within 48-72 hour (Alves, 2019).
During an ectopic pregnancy, the expectation for the beta HCG level is more than 15% within 48-72 hour (Josie, 2024).
During a gestational trophoblastic pregnancy, the expectation for the beta HCG level is to 46% within 48-72 hour (GoldStein, 2019).
Table 3
Common complaints during pregnancy.
Keep in mind these symptoms are during pregnancy, make sure the cause, presentation, and treatment is related to pregnancy status of the patient.
Definition and Cause
Presentation (include possible DDX)
Treatment
Education
Constipation
This is due to pregnancy predisposes women to constipation due to the rise in progesterone and delayed gastric motility (Jordan, 2018).
Difficult and painful defecation, hard stools, and feeling of incomplete evacuation (Jordan, 2018).
Adequate hydration, exercise routinely, fiber supplements such as Metamucil and a stool softener such as Colace (Jordan, 2018).
“The majority of cases are simple constipation that occurs due to a combination of hormonal, dietary, and mechanical factors affecting normal gastrointestinal (GI) function” (Jordan 2018).
Back pain
Influence of progesterone and relaxin which soften connective tissue including the ligaments and joints (Jordan, 2018).
“Lower backache is attributed to the lumbar lordosis required to counterbalance the weight of the growing uterus. Upper backache is caused by increasing weight of the breasts, postural factors, and employment requiring extended sitting” (Jordan, 2018).
Acetaminophen, pelvic floor exercises, and pelvic tilt exercises (Jordan, 2018).
Some factors that may cause lower back pain in pregnancy are occupation, heavy lifting, constant standing (Jordan, 2018).
GERD
Increased estrogen and progesterone cause the LES to relax which allows acid from stomach to flow back up
The second reason is because when the uterus grows it crowds the stomach and intestines which causes the stomach and acid to back up into the esophagus (Jordan, 2018).
Heartburn and acid reflux by eating spicy foods, drinking coffee, and eating too quickly (Jordan, 2018).
Avoid a large meal before bedtime, avoid caffeine, and encourage smaller meals. OTC medications, Antacids, and lastly, histamine 2‐receptor antagonists like ranitidine (Zantac) (Jordan 2018).
Serious reflux complications are uncommon in pregnancy (Jordan, 2018).
Fatigue
This is due to the increase of progesterone (Jordan, 2018).
Decrease of energy and/or motivation, insomnia, and a feeling of sadness, heaviness, or apathy (Jordan, 2018).
Daytime nap, adequate nighttime sleep, 30 minutes of daily exercise, and adequate protein intake (Jordan, 2018).
“Fatigue onset corresponding to 5–7 weeks’ gestation is the most significant clue as to the normal common discomfort of pregnancy or pathology.” (Jordan, 2018).
Heart palpitations
Increased blood volume and heart rate during pregnancy (Jordan, 2018).
Palpitations or ectopic beats are most commonly seen between 28 and 32 weeks’ gestation. Sinus tachycardia is seen in the third trimester due to the physiological increase in heart rate (Jordan, 2018).
“If the perception of palpitations is accompanied by dizziness, shortness of breath, or the woman has a history of cardiac problems, it is appropriate to have her evaluated by an obstetric or cardiac consultant immediately“ (Jordan, 2018).
Heart palpitations can be perceived as a pause in the regular heartbeat, followed by rapid palpitations. This symptom is often very concerning for the woman experiencing this (Jordan, 2018).
Urinary frequency
This is due to the uterus grows, it may press on the bladder causing a sensation of bladder fullness and the urge to urinate (Jordan, 2018).
The fetal head descends into the pelvis (Jordan, 2018)
“Voiding soon after feeling the urge, urinate 2–3 hours, urinating before and after intercourse, and reducing fluid intake in the later evening hours” (Jordan, 2018).
Urinary frequency tends to reoocur during the 3rdtrimester (Jordan, 2018).
Nausea and Vomiting
Increased levels of progesterone causing delayed gastric emptying (Jordan, 2018).
Typically starts around the sixth week of gestation, peaks at 9–11 weeks’ gestation, and tends to subside by 12–14 weeks’ gestation (Jordan, 2018).
Small frequency of meal, sip clear carbonated liquids, decrease dietary fats, avoid spicy foods, Benadryl, Compazine, Dramamine, Reglan, Zofran (Jordan, 2018).
Prescription pharmacologic measures are considered for women who report continuous, more severe Nausea and Vomiting (Jordan, 2018).
Round ligament pain
As the uterus expands in size and increases in weight, these ligaments are stretched like rubber bands (Jordan, 2018).
Shooting pain after a sudden movement or sharp, knifelike pain in the lower abdomen or on one side, typically the right side, extending into the groin area (Jordan, 2018).
Avoid sudden movement from sitting to standing, arise slowly from bed in the morning, and support the uterus with a pillow under the abdomen (Jordan, 2018).
“Round ligament pain can mimic symptoms of ectopic pregnancy, preterm labor, threatened abortion, and appendicitis” (Jordan, 2018).
Hyperpigmentation
Hyperpigmentation tends to decrease after birth, the nipples, areola, and genital areas do not usually return to their pre‐pregnant pigmentation (Jordan, 2018).
The areola, nipples, and genitalia also the axilla, inner thighs, and periumbilical (Jordan, 2018).
Topical treatments containing vitamin C or azelaic acid are helpful to lighten the patches
“Breast skin changes are seen on the areola with the development of a line of pigmentation surrounding the areola” (Jordan, 2018).
Sleep disturbance
Nighttime waking, insomnia, daytime fatigue, restless legs, and difficulty maintaining a comfortable sleep (Jordan, 2018).
The first trimester which suggests that sleep needs may increase in early pregnancy. The third trimester is characterized by a decrease in sleep time (Jordan, 2018).
The most common nonprescription medications that can help with sleep in pregnancy are antihistamines such as Benadryl, and Unisom, and melatonin.
Fresh air, relaxation, cutting caffeine, and eating healthy might improve sleep
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.
Subjective:
Chief Complaint: 2 mo amenorrhea, + pregnancy, LMP 5.6 weeks and has had some bleeding for the past 3 days.
HPI: 18 year-old female presents to the clinic for 2 mo/ amenorrhea. Patient stated that LMP was 5.6 weeks ago and is currently expecting. She is concerned about bleeding for the past 3 days that started as spotting and now has progressed to a light period. Denies pain, fever, cramps.
PMH: Iron-Deficiency Anemia
Past Surgical Hx: Wisdom Teeth Extraction (Dental)
Allergies: Flagyl
Family Hx:
Mother, 40, Alive, Lupus
Father, 45, Alive, Anemia
Brother, 15, Alive
Maternal Grandmother, 80, Alive, Diabetes
Maternal Grandfather, 83, Deceased, Brain Cancer
Paternal Grandmother, 85, Deceased, Heart Attack
Paternal Grandfather, 99, Deceased, Failure to Thrive
Social Hx:
Occupation, Social Worker
Alcohol, Does not drink
Substance Abuse, No hx of substance abuse
Sexual Hx: One male sexual partner
Are you having any fatigue? Are you having any fever? Are you having cramping? Are you having any pain? Have many partners have you been with sexually? Have you ever been pregnant? Do you have a support system? Do you feel safe at home? Have you received a pap smear? When did you become sexually active? Do you use condoms? Are you on birth control? Are you planning on keeping the baby when continuing the pregnancy? Would you like to learn about prenatal care?
ROS:
General: Alert and Oriented x4, speaks clearly and comfortably throughout.
BREAST: normal breast exam, Breasts, BL: no abnormalities, (-) erythema, (-) symmetric at rest, (-) symmetric with pectoral tension, (-) tender to palpation
Nipples, BL: no abnormalities, (-) discharge without pressure, (-) expressed discharge, (-) clear discharge, (-) bloody discharge, (-) purulent discharge, (-) bruising, (-) areolar bleeding
Axillae BL: no abnormalities, (-) mass, (-) tender to palpation, (-) erythema, (-)pectoral lymphadenopathy, (-)subscapular lymphadenopathy, (-)brachial lymphadenopathy, (-) acanthosis nigricans
RESP: lungs clear to auscultation bilaterally, no rales, wheezes or rhonchi, nonlabored breathing, no use of accessory of muscles of respiration.
CV: RRR, no m/r/g
GI: +BS, nontender to palpation, no masses, no HSM
GU/RECTAL: external genitalia NL appearance,
Urethral meatus: (-)lesions, (-) erythematous, (-)discharge, (-)tender
Bladder: normal, (-)tender, (-)cystocele
Vagina: NL appearance, NL pelvic support, (-)burning (-)discharge, (-)lesions, (-) fluid-filled vesicles
Cervix: moderate cervicitis, (-)lesions, (-)discharge, (+) bleeding, (+) spotting
Uterus: no abnormalities, NL position, NL mobility, (-)enlarged, (-)tender,
Adnexae, BL: no abnormalities, (-)tender, (-)masses, (-)enlarged,
Anus/rectum: no abnormalities, NL tone, (-)perianal lesions, (-)external hemorrhoids,
Rectal exam deferred: not indicated
DERM: skin warm and dry
Patient is not up to date on immunizations
Objective:
VS: BP: 110/72, HR:74, RR: 18, Temp: 98.3,O2 Sat: 97%, HT 62 inches WT: 130lb
General:
General: Alert and Oriented x4, speaks clearly and comfortably throughout.
BREAST: normal breast exam, Breasts, BL: no abnormalities, (-) erythema, (-) symmetric at rest, (-) symmetric with pectoral tension, (-) tender to palpation
Nipples, BL: no abnormalities, (-) discharge without pressure, (-) expressed discharge, (-) clear discharge, (-) bloody discharge, (-) purulent discharge, (-) bruising, (-) areolar bleeding
Axillae BL: no abnormalities, (-) mass, (-) tender to palpation, (-) erythema, (-) pectoral lymphadenopathy, (-) subscapular lymphadenopathy, (-)brachial lymphadenopathy, (-) acanthosis nigricans
RESP: lungs clear to auscultation bilaterally, no rales, wheezes or rhonchi, nonlabored breathing, no use of accessory of muscles of respiration.
CV: RRR, no m/r/g
GI: +BS, nontender to palpation, no masses, no HSM
GU/RECTAL: external genitalia NL appearance,
Urethral meatus: (-)lesions, (-) erythematous, (-)discharge, (-)tender
Bladder: normal, (-)tender, (-)cystocele
Vagina: NL appearance, NL pelvic support, (-)burning, (-)discharge, (-)lesions, (+) fluid filled vesicles
Cervix: moderate cervicitis, (-)lesions, (-)discharge, (+) bleeding, (+) spotting
Uterus: no abnormalities, NL position, NL mobility, (-)enlarged, (-)tender,
Adnexae, BL: no abnormalities, (-)tender, (-)masses, (-)enlarged,
Anus/rectum: no abnormalities, NL tone, (-)perianal lesions, (-)external hemorrhoids,
Rectal exam deferred: not indicated
DERM: skin warm and dry
Assessment: (listed below)
Diff Dx:
O26.851 Spotting complicating pregnancy
The pertinent positives includes a light period for 3 days, spotting
The pertinent negatives includes dizziness, fainting, fever, and trouble breathing.
O00.9 Ectopic pregnancy
The pertinent positives includes light vaginal bleeding
The pertinent negatives includes pelvic pain and the most common gestational stage is 6 to 10 weeks (Cleveland Clinic, 2024).
Final Diagnosis:
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.
O03. 9 Unspecified spontaneous abortion
The pertinent positives includes spotting to a light period for 3 days
The pertinent negatives includes cramping, discharge, pain around the pelvic area or back, and fast heartbeat (Mayo Clinic, 2024).
Tonia’s HCG levels are dropping fast as they are supposed to be at 18 – 7,340 mIU/mL (Forbes, 2024) 5 weeks from her LMP.
Plan: (listed below)
Dx Plan:
Pregnancy test – positive – confirm pregnancy
HCG levels – 1200 and now is 550 and dropping will recheck again in 48 hours
Ultrasound – positive – faint – will recheck in two weeks
Pap Smear – No Abnormal findings
STD Panel – No abnormal findings
Treatment Plan: Discuss all options with Tonia. There are two nonsurgical treatments which are letting the tissue pass on its own and medication. “The NICE guidelines recommend that you are given mifepristone first and another medication called misoprostol 48 hours later” (NICE, 2019). Recheck HCG levels in another 48 hours to determine plan. The surgical intervention is a D&C. Use pads to manage bleeding, rest, the bleeding is likely to taper off within a week. If having pain take, paracetamol. Emotional treatment will help such as www.mend.orgLinks to an external site. (CDC, 2024).
Education: In early pregnancy one might get some light bleeding called spotting and this is from the developing embryo planting itself on the wall of the womb (NHS, 2024). HCG levels should double within 48 hours of pregnancy from weeks 4 to 6. Since the HCG levels are trending downward this can be an indication of pregnancy loss. There is no cure for the HCG levels dropping. A healthy baby might still result, but it does not look promising seeing as HCG levels dropped in half within 2 days. Notify your partner to tell them and for support. Most of the tissue passes within 2 to 4 hours after the cramping and bleeding start. This can go on for 4 to 6 weeks. An OB will do an ultrasound to make sure that all the tissue passes. It is important to discuss that a miscarriage is not anyone’s fault. If no complications such as heavy bleeding or pelvic pain after a miscarriage you can resume sexual activity in 2 to 3 weeks from the miscarriage. Your menstrual cycle should start back up within 4 to 6 weeks and recovery should take you about 1 to 2 months, but all bodies are different. Birth control pills ca be started right away after a miscarriage or within the first 7 days (CDC, 2024). You can ovulate and become pregnant two weeks after a miscarriage if wanting to try again for a baby, if emotionally and physically ready. Since sexually active it is important to receive a pap smear for cervical cancer screening. A pap smear is also needed to test for any type of STI’s.
Referral/Follow-up: Follow up HCG levels drawn from a labcorp within 48 hours after visit to determine HCG levels. If bleeding persists after a week or developing a fever. Otherwise appointment in 2 weeks for f/u US to make sure the tissue has passed.
Recommend an annual physical exam and pap smear every three years.
2. Case Study #2
Tables 1
GA by weeks
Lab Testing and/or Diagnostic Testing
Medication
Expectations
6-10 weeks
NT test
Serum Markers
Pelvic exam
Ultrasound (dating/transvaginal)
Cervical length measurement
Genetic carrier screening
Infectious disease screen (Rubella immunity, syphilis, HIV)
Urine test
PAP
Prenatal
Folic Acid
Iron (If Iron deficiency anemia)
Vitamin D
Anti-Nausea med
Progesterone
Thyroid (if thyroid disorder)
Heartbeat detection
N/V
Fatigue + increased sleep
Breast tenderness/change in size
Frequent urination
Mood Swings
Slight weight gain
Routine prenatal care
Ultrasounds
Diet Nutrition changes
Precautions (avoiding strenuous activities/substances)
10-14 weeks
NT ultrasound
Blood tests (Chromosomal abnormalities)
CfDNA
CVS
Blood type + RH factor
Routine blood (cbc)
Urinalysis
Thyroid function tests
Ultrasound
Cystic Fibrosis carrier screening
Tylenol (pain relief)
Prenatal
Folic Acid
Iron (If Iron deficiency anemia)
Vitamin D
Anti-Nausea med
Progesterone
Thyroid (if thyroid disorder)
“Baby bump”
Reduced morning sickness
Increased energy
Weight gain
Development of fetal organs
Increased appetite
Decreased urination
Increase blood volume
Emotion change
15-20 weeks
MSAFP
Triple or Quad screen
Amniocentesis (offered) for high risk pts of chromosomal abnormalities
Anatomy scan (18-20 weeks)
RH Antibody
Glucose challenge
Thyroid function
BP monitoring
Cystic Fibrosis carrier check
Urinalysis
GDM medications (if diagnosed)
Tylenol (pain relief)
Prenatal
Folic Acid
Iron (If Iron deficiency anemia)
Vitamin D/Calcium
Anti-Nausea med
Progesterone
Thyroid (if thyroid disorder)
Fetal bump
Weight gain
Visible change on U/S
Gender
Breast change (enlarge)
Skin changing
Heartbeat
Maternity clothing
Prenatal classes start
20- 24 weeks
Routine blood test
Gestational diabetes screen
RH antibody
BP monitoring
U/S
Fetal Kick counts
Iron levels
Thyroid function
Urinalysis
Antibiotics (if bacterial infection)
GDM medications (if diagnosed)
Tylenol (pain relief)
Prenatal
Folic Acid
Iron (If Iron deficiency anemia)
Vitamin D/Calcium
Anti-Nausea med
Progesterone
Thyroid (if thyroid disorder)
Increased fetal movement
Larger baby bump
Weight gain
Continue skin change
Back pain/ligament
Breast changes
Increase for hunger
Urinary frequency
24-28 weeks
Gestational diabetes screen
RH antibody (if indicated)
Anemia screening
BP monitor
U/S
Fetal kick counts
Thyroid
Urinalysis
Rhogam (if indicated)
Antibiotics (if bacterial infection)
GDM medications (if diagnosed)
Tylenol (pain relief)
Prenatal
Folic Acid
Iron (If Iron deficiency anemia)
Vitamin D/Calcium
Anti-Nausea med
Progesterone
Thyroid (if thyroid disorder)
Increased baby bump
Baby movement patterns
Braxton Hicks
Breathing changes
Weight gain
Back Pain
Increased blood volume
Stretch marks
Sleep changing
Nesting
Pelvic Pressure
28-32 weeks
Rh antibody (if indicated)
Anemia Screen
BP monitor
GBS
Fetal kick counts
U/S
NST
Thyroid function
Urinalysis
Rhogam (If indicated)
BP medications (gestational hypertension)
Corticosteroids (if indicated)
Antibiotics (if bacterial infection)
GDM medications (if diagnosed)
Tylenol (pain relief)
Prenatal
Folic Acid
Iron (If Iron deficiency anemia)
Vitamin D/Calcium
Anti-Nausea med
Progesterone
Thyroid (if thyroid disorder)
Increased baby bump
Baby movement patterns
Breathing changes
Weight gain
Back Pain
Pelvic pressure
Swelling
Baby position
Nesting
34 weeks
Anemia screen
Rh antibody testing (if indicated)
BP monitoring
Fetal kick counts
U/S
NST
Thyroid function
Urinalysis
BP medications (gestational hypertension)
Corticosteroids (if indicated)
Antibiotics (if bacterial infection)
GDM medications (if diagnosed)
Tylenol (pain relief)
Prenatal
Folic Acid
Iron (If Iron deficiency anemia)
Vitamin D/Calcium
Anti-Nausea med
Progesterone
Thyroid (if thyroid disorder)
Heartburn/indigestion
Sleep changes
Weight gain
Baby positioning
Swelling
Braxton Hicks
Increased blood volume
Back pain
Pelvic pressure
Fetal movement
36 weeks
Anemia screen
Rh antibody testing (if indicated)
BP monitor
Fetal kick counts
U/S
NST
Pelvic exam
Thyroid
Urinalysis
GBS (some doctors)
BP medications (gestational hypertension)
Corticosteroids (if indicated)
Antibiotics (if bacterial infection)
GDM medications (if diagnosed)
Tylenol (pain relief)
Prenatal
Folic Acid
Iron (If Iron deficiency anemia)
Vitamin D/Calcium
Anti-Nausea med
Progesterone
Thyroid (if thyroid disorder)
Lightning crotch
Pelvic pressure
Braxton Hicks
Back pain
Increased urination
Gastrointestinal changes
Cervical changes
Nesting
Sleep changes
37 weeks onwards
GBS
Anemia screen
Rh antibody testing (if indicated)
BP monitor
Fetal kick counts
U/S
NST
Pelvic exam
BPP
Thyroid Function
Urinalysis
BP medications (gestational hypertension)
Corticosteroids (if indicated)
Antibiotics (if bacterial infection)
GDM medications (if diagnosed)
Tylenol (pain relief)
Prenatal
Folic Acid
Iron (If Iron deficiency anemia)
Vitamin D/Calcium
Anti-Nausea med
Progesterone
Thyroid (if thyroid disorder)
Pelvic pain/pressure
Sleep changes
Emotional changes
Nesting instinct
Gastro changes
Weight gain
Cervical changes
Braxton hicks + True contractions
A hospital visit to go into labor!
(Alexander, 2017).
Table 2
Scenario
A normal ongoing pregnancy, the expectation for the beta HCG level is to double within 48-72 hours
During a spontaneous abortion (miscarriage), the expectation for the beta HCG level is to _Decrease by 50% (hint: decrease by how much) within 48-72 hour
During an ectopic pregnancy, the expectation for the beta HCG level is to _increase at a slower rate or decrease___ within 48-72 hour
During a molar pregnancy, the expectation for the beta HCG level is to __increase rapid/abnormally within 48-72 hour
Case Study:
Lisa is a 29-year-old female G3P2 at 28 weeks EGA who is coming to the clinic for her routine checkup. She is Rh negative. Her VS are normal and prenatal routine screenings are WNL. Lisa asks if it is normal to be experiencing frequency and mild burning when she urinates which she says has increased over the last 2 days. She has been drinking more water recently and thinks that maybe this is causing the urinary frequency.
SOAP Note
Demographic Data: 29-year-old Female
Subjective
Chief Complaint (CC): “I have experienced frequency and mild burning when I urinate”
History of Present Illness (HPI): 29 y/o G3P2 female presents to the clinic this morning at 28 weeks gestation ℅ frequency and mild burning when urinating that has increased over the last two days.
O- When did you first start experiencing the frequency, and mild burning?
L- How often do you have frequency, and mild burning? How often are you using the bathroom? How many times during the night? Pt states it has increased over the last two days.
D- Is the frequency, and mild burning consistent?
C-Describe the amount of urine, and the characteristics (dark yellow, light yellow, ect)?
A- Do you experience any pain or discomfort associated with the frequency, and mild burning, any flank pain or back pain?
R- If yes, does anything relieve it, have you taken any OTC medications?
T- Have you noticed any changes including a fever?
What other relevant questions should you ask regarding the HPI?
Severity
1.How often are “accidents” occurring if any?
2.Do you leak urine when you cough, laugh, or sneeze?
3.Do you wear pads/protection while this is happening?
4.If yes, how many pads/day?
5.Does this problem interfere with your social life or work?
Infection, Malignancy
1.Do you have a history of bladder or kidney infections?
3.Have you ever had blood in your urine?
Voiding Dysfunction
1.Is the urine stream slow or intermittent?
2.Do you have to strain to get the urine out?
3.After urination, do you have dribbling or a sensation that your bladder is still full?
Urge/Detrusor Instability
1.Do you ever have an uncomfortable need to rush to the bathroom to urinate?
2.If yes, do you ever have an “accident” before you reach the toilet?
3.How many times during the day do you urinate?
7.Do you ever have leakage during intercourse?
(Alexander, 2017).
Past Med. Hx (PMH):
Do you have any past medical history/conditions?
Have you ever been hospitalized?
What other medical history questions should you ask?
Do you have a hx of previous urinary tract infections, especially during the current pregnancy? If so, when and what were you prescribed?
Have you had any recent illnesses or conditions that might compromise the immune system?
Inquire about recent sexual activity
Have there been any concerns or complications during the current pregnancy?
Have you noticed any fever or chills?
Have you noticed any lower back pain, in the mid back (kidney pain)?
LMP: When was your last menstrual period?
Gyn/OB history:
What other OB history questions should you ask?
Can you share with me any past experiences you’ve had with OB/GYN care or any specific concerns you may have? Have you felt the baby moving as normal? Any past STIS/STDS? Are there any specific family planning or reproductive health goals you’d like to discuss now that you are pregnant again? Do you use any scented products to clean your genital area? What is your typical genital hygiene routine?
What important lab results should you review prior to 28 weeks?
Blood type + RH factor
CBC
Blood glucose levels
Rubella immunity
Syphilis screen
Heb B + C screening
Genetic screening
Thyroid Function
STI screen
Urinalysis
Urine Culture
PAP
HIV
Cystic fibrosis carry
Ultrasound and Nuchal Translucency Screening
Past Surgical Hx
Have you had any surgeries in the past?
Family Hx
Do you have any family history of medical conditions? HTN, DM or any other cardiac/endocrine disease/cancer?
Mother
Father
Siblings
Grandmother
Grandfather
Current Medications
Are you currently taking any medications or OTC supplements?
Are you taking a prenatal vitamin?
Are you taking your medications as instructed/prescribed?
Have you taken anything OTC for your symptoms you are complaining about today?
Allergies
Do you have any allergies?
Immunizations History
Are you up to date on your immunizations?
Have you had the gardasil/HPV vaccine?
Covid vaccine?
Yearly flu vaccine?
Hep B?
Varicella?
MMR?
Tdap?- will be given today since pt is 28 weeks (27-36 weeks given approx).
Health Maintenance
-When was your last annual physical?
-When was your last Women’s wellness exam?
-When was your last PAP?
-When was your last eye exam ?
-When was your last dental visit ?
-Have you ever had a mental health examination?
-How is your diet? Do you exercise?
Social History
How long have you been sexually active with this partner?
How many intimate partners have you had?
Do you engage in oral, vaginal, or anal contact?
Do you have sex with males, females, or both?
Do you engage in alcohol or drug use?
Do you smoke tobacco or use tobacco products? If so, how long? How many packs a day?
What is your current living situation?
Do you feel safe where you live?
What do you do for work?
Any anxiety/depression?
How is your support system?
Review of Systems (ROS)
General: Do you have any malaise, fatigue and weakness? Any weight loss, fever & chills?
HEENT: Any recent, visual disturbance, nasal congestion, or sore throat?
Endocrine: Any history of diabetes or thyroid disorders?
Lymphatic: Any swelling in your lymph nodes?
Cardiovascular: Have you noticed any chest pain and discomfort? Any palpitation, edema, swelling of extremities or changes? Any history of heart attack or heart failure?
Respiratory: Any cough, shortness of breath, swelling? Any phlegm production?
Skin & Breasts: Have you noticed any rashes, itching, or abnormalities on your skin? Any recent injuries? Any breast pain, discharge?
GI: Have you had any recent N/V/D, constipation, or abdominal cramping or tenderness?
Musculoskeletal: Any weakness or pain in your joints?
Neuro: Have you had any recent headache, dizziness, or numbness/tingling in extremities?
Immunologic: Any hx of HIV?
Genitourinary/GYN: Pt reports dysuria, frequency and urgency on visit. Any hx of bladder/kidney stones/infections? Any abnormal or change in discharge?Any sexual dysfunction or concerns? How many days does a typical period last? How heavy is your flow? Do you have pain, cramps, or headaches with your period? At what age did you become sexually active? Do you have any pain with intercourse? What sort of birth control and protective measures do you use when not trying to conceive? Have you ever been diagnosed or had symptoms of an STI? Have you ever been tested for STIs? Have you ever used any contraceptive methods besides condoms?
Objective
5. Describe the appropriate physical assessment that needs to be included in this visit.
Abdominal examination- looking for tenderness
Pelvic examination/Cervical- looking for infection, swelling, discharge, overall appearance
Vital signs- temperature increase can be infection
Back pain assessment- CVA tenderness (UTI traveled)
Vital signs:
ALL WNL
General: Vital signs are stable, in no acute distress. Alert, well developed and well nourished.
HEENT: Normocephalic, atraumatic, no abrasions or bruising present, PERRLA, sclera white, no discharge present, uvula & tongue midline, no exudates present, bilateral nares patent, bilateral ear canals clear w/cone of light visualized bilaterally, thyroid midline with no tenderness or nodules noted on exam.
Cardiovascular: S1, S2 has regular rate/rhythm.
Respiratory/ chest: unlabored breathing, equal chest rise and fall with equal bilateral breath sounds.
Integumentary: No rashes or abnormal moles noted on visualized skin
Lymphatic: lymph nodes not palpable or tender
GI: soft, non-tender, non-distended. Bowel tones normoactive in all 4 quadrants
Musculoskeletal: Full ROM in all extremities, stable gait pattern
Neuro: Mood and affect intact.
Genital/Rectal/Urinary/GYN: Pt complains of very minimal suprapubic tenderness. No bladder bulges. No lesions, rashes, masses of swelling, no flank pain noted (CVAT) performed- would need to perform a full pelvic exam in the clinic to ensure.
Explain what test(s) you will order and perform, and discuss your rationale for ordering and performing each test.
Urinalysis/Urine Culture- Testing for a UTI, determine the specific bacteria
Pelvic Exam- Pregnant women with UTIs may be at an increased risk of complications, including pyelonephritis- also looking at color/consistency of discharge, signs of inflammation and vaginal pH.
CBC/electrolytes and serum creatine- Looking to ensure no systemic infection or inflammation
NAAT test- see if there is bacterial DNA associated with BV
Assessment (Diagnosis/ICD10 code)
7 +8. What is your diagnosis + differential diagnosis?
Differential DX:
Bacterial vaginosis N77. 1
BV infection has been linked to miscarriage, chorioamnionitis, premature rupture of fetal membranes, preterm labor, and delivery. Women with BV can have no symptoms or have a malodorous discharge. Some may encounter mild irritation, vulvar pruritus, postcoital spotting, irregular bleeding episodes, or vaginal burning after intercourse, while others may report urinary discomfort. Testing for BV is recommended in the early second trimester (this patient) for symptomatic pregnant women at risk of preterm labor, and for high-risk women reporting increased vaginal discharge or preterm labor symptoms. The efficacy of BV treatment in asymptomatic pregnant women at high risk for preterm delivery has been assessed in various studies, yielding mixed results (Alexander, 2017).
(+) Burning while urinating
(-) Abnormal discharge
(-) Itching/irritation
(-) Fish-like odor
Working DX:
Unspecified infection of urinary tract in pregnancy, unspecified trimester O23.40
Pregnancy induces urinary tract changes that make women more susceptible to infection. Ureteral dilation occurs as the gravid uterus compresses the ureters. Additionally, the hormonal effects of progesterone can induce smooth muscle relaxation, resulting in dilation and urinary stasis. The most frequently isolated organism is Escherichia coli. If left untreated, bacteriuria can elevate the risk of preterm delivery, low-birth-weight infants, and gestational hypertension (Alexander, 2017)
(+) Pain/burning during urination
(+) Urinary frequency
(+) Urinary urgency
(+) Cloudy Urine
(-) CVA tenderness
(-) Fever/chills
TX Plan (POCT):
Urinalysis and clean catch urine culture
Pelvic exam
Diagnosis is made based on symptoms and/or urinalysis with a culture for sensitivity. A urine specimen is obtained for a urine dip, and a positive nitrite and/or leukocyte reading is indicative of a UTI. A urinalysis will reveal pyuria and bacteriuria. Most clinicians will treat a pregnant patient with complaints of a UTI, whether or not the urine dip is suspicious for infection (Alexander, 2017). All patients should be screened for UTI, have their postvoid residual (PVR) measured, and have simple cystometric studies done (Alexander, 2017).
In clinic Testing to be sent out
Complete blood count (CBC), electrolytes and serum creatine.
NAAT test for BV
Treatment plan
What will you prescribe for this patient? Why? Explain what medications and treatments you would recommend. HINT: patient should be receiving at least 2 injectable medications at this visit plus oral medication
Nitrofurantoin 100 mg BID for 7 days
Treatment using a 3-day regimen is 90% effective in curing bacteriuria (book). Clinicians should treat acute cystitis in pregnant individuals with a 5–7-day course of a targeted antibiotic. If empiric therapy is started before culture and sensitivity results are available, amoxicillin or ampicillin regimens should be avoided due to high rates of resistance in Escherichia coli to these antibiotics in most areas (ACOG, 2022).
Tdap- protects mother and baby from Pertussis
Rh(D) Immunoglobulin (RhIg) Injection – patient is RH negative, given about 28 weeks as a preventive measure to reduce the risk of Rh isoimmunization.
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.
– See below
11.Explain complications that can occur if a patient does not comply with the treatment regimen.
-See below
Medication Education
-Take the medication exactly as prescribed by the healthcare provider.
-Follow the recommended dosage and schedule.
-Take with food
-Side effects: N/V and mild gastrointestinal symptoms.
-Finishing all antibiotics even if symptoms improve before they are finished can develop antibiotic resistance or not clear the entire infection and become a systemic/kidney infection.
Pt. Education for DX:
Drink lots of fluids
Vitamin C and cranberry juice are recommended.
Finish all antibiotics even if symptoms subside
Stay out of hot tubs, pools, baths
Loose fitting clothing
Do not use douching
Maintain good hygiene
Keep a journal about symptoms
OTC pain relievers
Do not resume vaginal intercourse until symptoms have subsided and antibiotics are completed.
Limit/avoid alcohol during antibiotics
Referral/Follow-up:
When should the patient return?
F/U in clinic within a week of completing the course of antibiotics. Symptom assessment, and urinalysis will be performed to ensure cleared infection. Will call with culture results.
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