NRNP 6552 Common Health Conditions With Implications For Women

NRNP 6552 Common Health Conditions with Implications for Women

NRNP 6552 Common Health Conditions with Implications for Women

Episodic/Focused SOAP Note Template

Patient Information:

BB, 39, F, undisclosed

S.

CC: Positive home pregnancy

HPI: Bonita Bubble is a 39-year-old female presenting today at your clinic with a positive home pregnancy test. She reports breast tenderness, fatigue, and nausea, which made her suspect she is pregnant.

Current Medications:

Woman’s vitamin daily

Allergies:

No known medication, latex, or environmental allergies

PMHx:

Disappearing twin

Ectopic Pregnancy- Treated with methotrexate

Surgical Hx:

C/s for breech after failed version

Soc & Substance Hx:

Patient is a mother of 3.

Fam Hx:

Non-contributory

Mental Hx:

Denies

Violence Hx:

Denies

Reproductive Hx: G42123. LMP 4/24/2023. First menses age 12. Menstrual cycles every 28 days and lasting for 5 days. Pap and STD history are negative.

ROS:

GENERAL: + Fatigue. Denies weight loss, fever, chills, weakness

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: + Breast tenderness. Denies breast pain or discharge. Denies rash or itching.

CARDIOVASCULAR: Denies chest pain, chest pressure, or chest discomfort. No palpitations or edema.

RESPIRATORY: Denies SOA shortness of breath, cough, or sputum.

GASTROINTESTINAL: + Nausea. No anorexia, vomiting, or diarrhea. No abdominal pain or blood.

NEUROLOGICAL: Denies headache, dizziness, syncope, paralysis, ataxia, numbness, or tingling in the extremities. No change in bowel or bladder control.

MUSCULOSKELETAL: Denies muscle pain, back pain, joint pain, or stiffness.

HEMATOLOGIC: Denies anemia, bleeding, or bruising.

LYMPHATICS: Denies enlarged nodes. No history of splenectomy.

PSYCHIATRIC: Denies history of depression or anxiety.

ENDOCRINOLOGIC: Denies reports of sweating or cold or heat intolerance. No polyuria or polydipsia.

GENITOURINARY: + Breast tenderness. Denies dysuria. No vaginal discharge or pain

ALLERGIES: Denies history of asthma, hives, eczema, or rhinitis.

O.

CARDIOVASCULAR: S1 S2 on auscultation, RRR. No carotid bruits. No murmurs, gallops, or rubs. 2+ Radial and pedal pulses bilaterally

RESPIRATORY: Equal chest rise and fall. No nasal flaring. Normal respiratory effort. No rales/crackers/rhonchi

GASTROINTESTINAL: BS present x 4. Abdomen is soft, symmetric, non-tender w/o distention, no masses

ENDOCRINOLOGIC: Thyroid is midline, soft, smooth, symmetrical, non-tender, and slides upward with swallowing. 

GENITOURINARY: Generalized bilateral breast tenderness. No pain. No lumps. No nipple discharge.

Diagnostics:

Pelvic ultrasound- confirm pregnancy, determine viability, provide gestational age, and r/o ectopic

Prenatal Panel- to determine the mother’s overall health, check for diseases, or illnesses that could be harmful to the fetus

A.

Primary Diagnosis

Secondary Amenorrhea ICD-10 code N91. 2 

Differential Diagnosis

1. Positive pregnancy test (ICD 10 code Z32.01) 
2. Normal pregnancy (ICD-10 code 9)
3. Ectopic pregnancy (ICD-10-CM 9)

The most crucial diagnosis for this patient is secondary amenorrhea. Secondary amenorrhea is the absence of a menstrual period for three months or more (Amenorrhea: Absence of Periods, 2020). Amenorrhea is a symptom of several health conditions. However, regardless of the possible cause, the first priority is to rule out pregnancy. According to Nawaz and Rogol (2023), the most common cause of amenorrhea is pregnancy. The patient, in this case, study reports a positive home pregnancy test. As a practitioner, my first priority is to confirm the viability of the pregnancy. A transvaginal ultrasound would confirm pregnancy, and establish the pregnancy’s location, viability, and fetal gestational age (Lee et al., 2022).

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Once pregnancy is confirmed, I recommend an ABO Group and RHO(D) Typing to determine the patient’s blood type and establish if she is a candidate to receive Rh immune globulin. A Comprehensive Metabolic Panel (CMP) checks the patient’s kidneys and liver function. A Complete Blood Count (CBC) assists in diagnosing conditions that could cause amenorrhea such as anemia, clotting disorders, or infections. Fetal growth and development are associated with maternal lipid concentrations, therefore a Lipid panel is an important laboratory test. A Thyroid Panel with TSH is necessary to monitor the thyroid’s hormone concentrations and determine if there are any deficiencies. A Human Immunodeficiency virus (HIV) test establishes the patient’s status. A positive woman for this virus can transmit it to the fetus. A Rapid Plasma Reagin (RPR) checks for syphilis which can be fatal to the fetus. The Rubella Antibodies IgG test determines if the patient has immunity to rubella. A mother infected with rubella during pregnancy puts her baby at risk for birth defects. Hepatitis B and C are transmittable viruses to the fetus resulting in complications. The patient is of advanced maternal age. Due to her age, I would also order Noninvasive Prenatal Testing (NIPT). NIPT screening is used to detect congenital abnormalities such as Down Syndrome or Trisomy 13 and determines the gender of the fetus.

Treatment recommendations for this patient include taking a prenatal vitamin with 800 mcg of folic acid. It is unknown when she last had a pap smear. I would recommend that the patient complete this test to determine the health of her cervix. I would advise the patient to avoid any alcohol, no smoking, maintain a healthy diet, regular exercise, and increase her water intake. I would also discuss concerns about any abuse. I would inform the patient to give notice if she develops heavy vaginal bleeding, abdominal or pelvic pain, severe nausea/vomiting, fevers not relieved by Tylenol or headaches that do not subside after a day. 

References

Amenorrhea: Absence of Periods. (2020). Www.acog.org. https://www.acog.org/womens-health/faqs/amenorrhea-absence-of-periods

Lee, W. A., Nelson, G., & Grogan, S. P. (2022). Sonography 1st Trimester Assessment, Protocols, And Interpretation. PubMed; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK573070/

Nawaz, G., & Rogol, A. D. (2023). Amenorrhea. PubMed; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK482168/#:~:text=There%20are%20primary%20and%20secondary

Thanks for sharing your discussion about a positive home pregnancy test. This post is highly informative and thorough. You have highlighted some crucial points. I am in complete agreement with the statement that you have made. You stated that” my priority is to confirm the viability of the pregnancy.” I vehemently believe that this approach will prevent misdiagnosis. Also, the benefits of this approach will facilitate the following: allow healthcare professionals to provide accurate treatment, monitor pregnancy progress, assess the risk of pregnancy, find out gestational age, and provide expectant mothers with guidelines that will aid in the decision-making process regarding family planning and childbirth. 

It is crucial to know that the confirmation of pregnancy is done by ordering some diagnostic investigations. In addition to the diagnostic tests you mentioned, I would like to add some tests that might be appropriate and suitable at the different stages of pregnancy. The possible diagnostic tests to confirm pregnancy are Serum Human Chorionic gonadotropin  (HCG) Tes, fetal heart rate monitoring with a Doppler device, and pelvic exam.

It is widespread to use HCG to screen for pregnancy. This qualitative point-of-care test is performed to reduce the negative impact on Maternal Fetal health. A rapid qualitative serum HCG testing will facilitate a 1-hour turnaround time for results. This will help the clinician to provide appropriate treatment (Mattiello & Stickle, 2023).

The well-being of a fetus is assessed by monitoring the fetal rate. A Doppler ultrasound scans the fetal heart rate before and after labor. An ultrasound transducer is placed on the abdomen of the expected mother to monitor the heart rate continuously. On the contrary, a handheld Doppler transducer is used to obtain intermittent measurements (Hamelmann et al., 2020).

Pelvic examination plays an integral role in the patient who presents with intrauterine gestation. This exam provides additional and pertinent information for certain obstetrics conditions. The pelvic examination includes using a speculum and bimanual examination to assess any changes in the cervix and uterus that indicate that a woman is pregnant. This examination also facilitates the collection of cervical cultures (Tucker & Evans, 2019).

In conclusion, confirming the viability of a pregnancy is essential In obstetrics. The various available diagnostic tests will help ensure that the fetus and expected mother receive appropriate treatment.

References

Hamelmann, P., Vullings, R., Kolen, A. F., Bergmans, J. W., van Laar, J. O., Tortoli, P., & Mischi, M. (2020). Doppler ultrasound technology for Fetal Heart Rate Monitoring: A Review. IEEE Transactions on Ultrasonics, Ferroelectrics, and Frequency Control, 67(2), 226–238. https://doi.org/10.1109/tuffc.2019.2943626

Mattiello, C. J., & Stickle, D. F. (2023). Characterization by image analysis of the dose vs response curve for a qualitative serum hcg lateral flow immunoassay. Clinica Chimica Acta, 538, 175–180. https://doi.org/10.1016/j.cca.2022.11.020

Tucker, P., & Evans, D. D. (2019). Are pelvic exams necessary anymore? Advanced Emergency

Primary and Differential Diagnoses

Pregnancy (Z34.90) Breast soreness, nausea, vomiting, frequent urination, missed period, and gaining weight are all symptoms of pregnancy, as described by Foxcroft et al. (2013). In addition to these, you may also experience: extreme tiredness, spotting, enlarged and tender breasts, bloating, mood swings, an elevated basal body temperature, or stretch marks. Some of the symptoms were present, and a home pregnancy test was positive for this patient. The most likely diagnosis is pregnancy.

Ectopic pregnancy (O00.90) An ectopic pregnancy is one that develops in a location other than the uterus, most frequently in one of the fallopian tubes, as stated by Hendriks et al. (2022). Previous ectopic pregnancy, past surgery on the fallopian tubes, prior surgery on the pelvic or abdominal region, pelvic inflammatory disease (PID), certain sexually transmitted infections, and endometriosis are all considered risk factors for ectopic pregnancy. Symptoms include those of a regular pregnancy, including some of the same indicators, such as a missing menstrual period, sensitive breasts, or nausea. Other possible symptoms include bleeding from the vagina and pain or cramping in the lower abdomen on one side. Because the patient has a history of ectopic pregnancy and a positive pregnancy test, this diagnosis is a distinct possibility in their case. A transvaginal ultrasound and a blood test for beta-human chorionic gonadotropin would both be required to confirm this diagnosis.

Hypothyroidism (E03.9) Hypothyroidism, as defined by Chaker et al. (2022), occurs when the thyroid gland fails to produce enough thyroid hormones. When your body doesn’t get enough thyroid hormone, a lot of things slow down. Fatigue, weight gain, heavy or irregular periods, inability to tolerate cold, and aching muscles and joints are all symptoms. Although this could be the case, the patient’s positive at-home pregnancy test rules out this diagnosis.

Diagnostic test

The purpose of the first meeting is to determine whether or not you are pregnant, assess your overall health, and look for any potential risks to the health of your unborn child. Urine or serum B-HCG, as well as transvaginal or transabdominal ultrasound, are all methods that can be used to confirm a pregnancy (American College of Obstetricians and Gynecologists, 2022).

• B Hcg
• PAP w/HPV
• CBC
• Blood type and Rh factor
• Rubella
• Hep B and Hep C
• HIV
• Gonorrhea
• RPR
• Chlamydia
• Transvaginal ultrasound
• Natera test

Treatment

Consuming a good diet, taking prenatal vitamins, engaging in regular exercise, being aware of potential dangers, and maintaining current immunizations are all essential components of a healthy pregnancy (Grenier et al., 2020).

• Prenatal vitamins 1 PO daily
• Stay active
• Stay hydrated drink a minimum of 8-8oz bottle of water per day
• Eat 5-6 small meals
• Eat healthy snacks between meals
• Do not eat greasy, fatty, or spicy foods
• Avoid smells

References

Chaker, L., Razvi, S., Bensenor, I. M., Azizi, F., Pearce, E. N., & Peeters, R. P. (2022). Hypothyroidism. Nature Reviews Disease Primers, 8(1). Retrieved July 18, 2023, from Links to an external site.https://doi.org/10.1038/s41572-022-00357-7

Links to an external site.

Foxcroft, K. F., Callaway, L. K., Byrne, N. M., & Webster, J. (2013). Development and validation of a pregnancy symptoms inventory. BMC Pregnancy and Childbirth, 13(1). Retrieved July 18, 2023, from Links to an external site.https://doi.org/10.1186/1471-2393-13-3

Links to an external site.

Grenier, L. N., Atkinson, S. A., Mottola, M. F., Wahoush, O., Thabane, L., Xie, F., Vickers‐Manzin, J., Moore, C., Hutton, E. K., & Murray‐Davis, B. (2020). Be healthy in pregnancy: Exploring factors that impact pregnant women’s nutrition and exercise behaviours. Maternal & Child Nutrition, 17(1). Retrieved July 18, 2023, from Links to an external site.https://doi.org/10.1111/mcn.13068

Links to an external site.

Hendriks, E., MD, Rosenberg, R., MD, & Prine, L., MD. (2020). Ectopic pregnancy: diagnosis and management. American Family Physician, 101(10), 599–606. Retrieved July 18, 2023, from Links to an external site.https://www.aafp.org/pubs/afp/issues/2020/0515/p599.html

Links to an external site.

Pregnancy at age 35 years or older. (2022, August). The American College of Obstetrics and Gynecologist. Retrieved July 18, 2023, from Links to an external site.https://www.acog.org/clinical/clinical-guidance/obstetric-care-consensus/articles/2022/08/pregnancy-at-age-35-years-or-older