unit9assgntclinics

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Introduction:

In this case study, we will be discussing Jane, a 42-year-old G4P2103 who presents with menopause symptoms but is later found to be pregnant. We will examine her subjective and objective findings, diagnostic and laboratory testing needed, differential diagnoses with rationales, medications and treatments needed, patient education required and referrals for collaborative care with rationales.

Description of the case chosen:

Jane is a 42-year-old G4P2103 who has been experiencing irregular and heavy menses for 6 months, followed by an abrupt stop in menses 3 months ago. She has been experiencing nausea, vomiting, gaining weight and breast tenderness for the last few months. Jane comes to the clinic today to discuss menopause symptoms and treatment. During the visit, a urine pregnancy test came back positive. During the exam, you palpate a 16-week-size uterus and get fetal heart tones of 165.

Subjective data, identify both given and needed data:

Given subjective data:
– Irregular and heavy menses for 6 months
– Menses stopped abruptly 3 months ago
– Nausea and vomiting for 6 weeks
– Weight gain and breast tenderness for the last few months
– Comes to the clinic to discuss menopause symptoms and treatment

Needed subjective data:
– Any existing medical conditions, especially those that could affect pregnancy
– Past pregnancies and complications
– Birth control history
– Sexual history
– Any medication or drug use
– Family history of genetic conditions or birth defects

Objective findings, identify both given and needed data:

Given objective data:
– Urine pregnancy test positive
– Palpated a 16-week-size uterus
– Fetal heart tones of 165

Needed objective data:
– Blood pressure, heart rate, and respiratory rate
– General physical exam, including a breast exam
– Pelvic exam to rule out complications
– Ultrasound to confirm pregnancy and evaluate fetal growth
– Blood tests to evaluate hormonal levels and rule out any underlying conditions

Diagnostic or laboratory testing needed with rationales:

– Ultrasound to confirm pregnancy and evaluate fetal growth
– Complete blood count (CBC) to evaluate for anemia
– Blood tests to check hormone levels, such as thyroid-stimulating hormone (TSH), follicle-stimulating hormone (FSH), and luteinizing hormone (LH)
– Screening for sexually transmitted infections (STIs), including HIV, syphilis, and chlamydia
– Pap smear to check for cervical cancer

List of three differential diagnoses with rationales:

1. Pregnancy-related complications – Jane’s symptoms could be related to pregnancy, including morning sickness, breast tenderness, and weight gain. It is necessary to evaluate the pregnancy for any complications, such as preeclampsia or gestational diabetes.

2. Menopause – Jane’s symptoms could be due to menopause. However, given the positive pregnancy test, it is less likely.

3. Uterine fibroids – Heavy menses and a large uterus could be indicative of uterine fibroids. An ultrasound can confirm this diagnosis.

Medications and or treatments needed with rationales:

– Folic acid supplements to prevent neural tube defects in the developing fetus
– Prenatal vitamins to ensure proper nutrition for both the mother and the fetus
– Nausea medication to help with morning sickness
– Blood pressure medication if preeclampsia is diagnosed

Patient education needed:

– Healthy eating habits for pregnancy
– Proper exercise routines
– The importance of taking prenatal vitamins
– The importance of quitting smoking, drinking alcohol or using drugs during pregnancy
– Warning signs of pregnancy complications

Referrals for collaborative care needed with rationales:

– Referral to an OB/GYN for prenatal care
– Referral to a nutritionist for dietary counseling during pregnancy
– Referral to a genetic counselor if any genetic conditions are found in the family history

Summary of the case study and further research, diagnostics, procedures, or follow-up needed:

Jane, a 42-year-old G4P2103, presents with symptoms that are suggestive of menopause but is found to be pregnant during the clinic visit. Further diagnostic testing, such as an ultrasound, blood tests, and pelvic exams, is necessary to monitor the pregnancy and rule out any complications. Medications such as prenatal vitamins and folic acid are needed during pregnancy. Patient education regarding healthy habits during pregnancy is necessary. Referrals to an obstetrician, nutritionist, and genetic counselor may be necessary. Follow-up visits will be necessary to monitor fetal growth and maternal health.

Evidence-based references:
1. American College of Obstetricians and Gynecologists (ACOG). (2017). Obstetric care consensus no. 6: Periviable birth. Obstetrics and Gynecology, 126(6), e82-e94.
2. National Institute of Child Health and Human Development (NICHD) Maternal-Fetal Medicine Units Network. (2016). A randomized trial of antenatal betamethasone for women at risk for late preterm delivery. New England Journal of Medicine, 374(14), 1311-1320.
3. American College of Obstetricians and Gynecologists (ACOG). (2018). Practice bulletin no. 190: Gestational diabetes mellitus. Obstetrics and Gynecology, 131(2), e49-e64.