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Reply to this case study and explain how you might think differently about the types of tests or treatment options your colleagues suggested and why. Use your learning resources and/or evidence from the literature to support your position. Initials: PH, Age: 39-year-old, Sex: Female, Race: Caucasian S. CC (chief complaint): “positive pregnancy test.” HPI: PH is a 39-year-old female who came to the clinic with a positive home pregnancy test. She states that she missed her period and her last period was 4/4/2022. She reports her associated symptoms include breast tenderness, fatigue, and nausea which made her suspect she was pregnant. Denies use of illicit substances. Current Medications: Woman’s vitamins for the last six years. Allergies: No reports given on family history. PMHx: Denies past medical issues. Soc & Substance Hx: Denies smoking tobacco, drinking alcohol, and taking illicit drugs. Fam Hx: No reports given on family history. Surgical Hx: The patient reports c-section for breech birth in 2017 Mental Hx: Denies history of depression and anxiety. Violence Hx: Denies sexual and physical abuse. Reproductive Hx: Menstrual history: LMP 4-4-2022, 1st menses age 12, with regular cycles coming every 28 days and lasting for five days. Pregnant: G5P3313. The patient was pregnant in 2015; she gave birth through epidural, and in 2016 she also gave birth to disappearing female twins. In 2017 she also gave birth through a C-section as the baby was breech. In 2019 she had an ectopic pregnancy at six weeks and was treated with methotrexate. According to her last menstrual period, she is now 15 weeks pregnant. Currently, she is not lactating. More information on contraceptives was not given. Denies being diagnosed with sexually transmitted diseases. Denies regular going for pap smears. ROS: GENERAL: Reports fatigue. Denies weight loss, chills, and fever. HEENT: Denies Eyes: No eye problems or vision changes. Ears: denies tinnitus or hearing loss. Nose: denies nose drainage, or congestion. Throat: denies sore throat or discomfort. SKIN: Denies bruises or edema. CARDIOVASCULAR: Denies chest pain, heart palpitations, and blood clots. RESPIRATORY: Denies breathing difficulties, production of sputum, and cough. GASTROINTESTINAL: Reports nausea. Denies changes in bowel movement and diarrhea. NEUROLOGICAL: Denies headache, dizziness, tingling, and changes in bowel control. MUSCULOSKELETAL: Denies muscle and back pain. HEMATOLOGIC: Denies excessive bleeding. LYMPHATICS: Denies swollen lymph nodes. PSYCHIATRIC: Denies history of depression or anxiety. ENDOCRINOLOGIC: Denies cold and heat intolerance. GENITOURINARY/REPRODUCTIVE: Denies Burning on urination. Reports positive home pregnancy. She has also been pregnant before this is the fifth pregnancy. LMP 4-4-2022. Reports breast tenderness. No reports of vaginal discharge and sexual activity. ALLERGIES: No know allergies O. Physical exam: No report on a physical exam was given. In this case, I would perform assessment on following systems; Vital Signs: To determine high blood pressure, pulse and other vitals. Lungs/CV: Chest is clear to auscultation bilaterally, normal respiration, rhythm. Breast: soft, no tenderness, or masses to palpation. Abdominal: soft, non-tender, non-distended, no trauma on inspection, normal bowel sounds all 4 quadrants, no masses noted on light or deep palpation, no CVA tenderness, no hepatosplenomegaly, suprapubic tenderness. Determine fundal height Genitalia: Cervix: firm, smooth, no cervical motion tenderness. Uterus: RV, mobile,?non-tender. Adnexa: without masses or tenderness, Perineum: intact no warts or lesion noted, Rectum: Intact no bleeding or lesion noted. Diagnostic results: Which diagnostic tests I would recommend for the patient. Abdominal Ultrasound test- To confirm pregnancy and the fetal measures to confirm exact days and fluid. An ultrasound is needed to check for abnormalities like ectopic pregnancy (Oyatogun et al., 2021). Serum Human chorionic gonadotropin (HCG). To confirm for pregnancy. During pregnancy, HCG hormones rise; therefore, the presence of this hormone would indicate pregnancy (Oyatogun et al., 2021). Urinalysis. To check infections. A. Primary Diagnosis Early pregnancy. Early pregnancy symptoms are missed periods, nausea, breast tenderness, and fatigue (Sapra et al., 2017). This is the primary diagnosis because the patient has all early pregnancy symptoms. The patient’s last menstrual period was 4/4 2022, and she usually has regular periods meaning missed periods. She also has nausea, fatigue, and breast tenderness, which are early pregnancy symptoms. Differential Diagnoses. Pituitary hCG production. This is a condition in which the pituitary produces a high number of hCG hormones from negative feedback and may cause false pregnancy tests (Sapra et al., 2017). Ectopic pregnancy- occurs when a fertilized egg implants and grows outside the main cavity of the uterus. An ectopic pregnancy most often occurs in a fallopian tube, which carries eggs from the ovaries to the uterus. This type of ectopic pregnancy is called a tubal pregnancy. By patient past history this will be one of my DDX. Gestational trophoblastic disease (GTD) is the name for abnormal cells or tumors that start in the womb from cells that would normally develop into the placenta. They are extremely rare but can happen during or after pregnancy. Most are non-cancerous (benign) but some are cancerous. They are different to womb cancer. P. Diagnostic studies. Studies show that early signs of pregnancy include morning sickness, fatigue, food aversion, sore breast, missed periods, and others (Sapra et al., 2017). During the pregnancy, the placenta produces hCG leading to a positive pregnancy test. Blood work orders, CBC + diff, CMP< TSH, liver panel, urine tests, and a glucose tolerance test, pelvic exam, your doctor also will check for sexually transmitted diseases (STDs) like chlamydia and gonorrhea. Maternity 21, CF, Vaginal cultures and Pap smear. Referral- to Maternal Fetal Medicine- to evaluation and recommendations for high risk. Pharmacologic and no pharmacologic treatments. Prenatal vitamins- folic acid. Education. Patient to be educated to avoid alcohol and smoking. The patient will also be educated to take prenatal vitamins as prescribed. Planned follow-up visits. The patient to come to the clinic in 3 weeks for a checkup. Reflection In this case I do not need to agree or disagree with my preceptor. The lack of information provide in this scenario make difficult the assessment. Interesting case for patient ages my decision is referral to MFM with all the laboratories and sonography details for evaluation and recommendations. References Oyatogun, O., Sandhu, M., Barata-Kirby, S., Tuller, E., & Schust, D. J. (2021). A rational diagnostic approach to the "phantom hCG" and other clinical scenarios in which a patient is thought to be pregnant but is not. Therapeutic Advances in Reproductive Health, 15, 263349412110164. https://doi.org/10.1177/26334941211016412 Sapra, K. J., Joseph, K. S., Galea, S., Bates, L. M., Buck Louis, G. M., & Ananth, C. V. (2017). Signs and Symptoms of Early Pregnancy Loss: A Systematic Review. Reproductive Sciences, 24(4), 502–513. https://doi.org/10.1177/1933719116654994 Ning F, Hou H, Morse AN, Lash GE. Understanding and management of gestational trophoblastic disease. F1000Res. 2019 Apr 10;8:F1000 Faculty Rev-428. doi: 10.12688/f1000research.14953.1. PMID: 31001418; PMCID: PMC6464061. Mummert T, Gnugnoli DM. Ectopic Pregnancy. [Updated 2021 Dec 9]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK539860/