Pregnancy Complications Case Study
Jane is a 42 year old G4P2103. Jane is divorced and works
hard long hours as a real estate agent. Jane was having irregular and heavy
menses for 6 months and then abruptly 3 months ago they completely stopped.
Jane has been having nausea and vomiting for 6 weeks but attributed it to
having the flu recently. She also admits
to gaining about 10 pounds in the last few months and breast tenderness. Jane comes to the clinic today to discuss
menopause symptoms and treatment. During the visit a urine pregnancy test came
back positive, on exam you palpate a 16 week size uterus and get fetal heart
tones of 165. Jane is in disbelief.
Instructions
Subjective data, identify both given and needed data
Objective findings, identify both given and needed data
Diagnostic or laboratory testing needed with rationales
List of 3 differential diagnoses with rationales
Medications and or treatments needed with rationales
Patient education needed
Referrals for collaborative care needed with rationales
Make sure to address all sections. Do not leave any section blank.
- Include relevant subjective and physical objective findings.
- Identify appropriate diagnostic and laboratory testing needed.
- List at least three differential diagnoses with rationales for choosing.
- Identify usual medications, treatments, or patient education needed.
- Determine referrals for collaborative care.
- Summarize the case study and include any further research, diagnostics, procedures, or follow-up needed.
- Provide evidence-based references
- use APA 6th Edition format,
- APA formatting and citing
- References less than 5 yrs old
Expert Solution Preview
Introduction:
A 42-year-old woman comes to the clinic complaining of menopause symptoms. During the visit, it is discovered that she is pregnant, exhibiting a 16-week size uterus, and fetal heart tones of 165. The case study mentions both subjective and physical objective findings. This assignment requires identifying given and needed data, laboratory testing requirements, differential diagnoses, medications or treatments, patient education, referrals for collaborative care, and further research that may be required. Evidence-based references that are less than five years old should be used.
Subjective data:
Given data: Jane is a 42-year-old G4P2103 who works long hours as a real estate agent. Jane was having irregular and heavy menses for 6 months and then abruptly ceased 3 months ago. Jane has been having nausea and vomiting for 6 weeks and has attributed it to having the flu recently. She has also gained about 10 pounds in the last few months, and she has breast tenderness.
Needed data: Medical history, including any prior pregnancies. Jane’s overall health status, use of prescription medication, and if not on any prescription medication why not. Family history of health conditions.
Objective findings:
Given data: Palpation reveals a 16-week size uterus, and fetal heart tones of 165.
Needed data: A pelvic exam should be performed. Abnormal skin and eyes should be checked for signs of thyrotoxicosis. Blood tests for diabetes, complete blood count and thyroid function should be taken.
Diagnostic or laboratory testing needed with rationales:
Pelvic ultrasound should be conducted to determine the pregnancy stage. TSH, random plasma glucose, and Hct/Hb should be tested to determine any problems that the pregnancy and/or new symptoms Jane might be experiencing.
List of 3 differential diagnoses with rationales:
(1) Possible ectopic pregnancy because Jane exhibits irregular menses, 6-weeks of nausea and vomiting, and tender breasts.
(2) Molar pregnancy with symptoms of nausea, vomiting, painful breasts, and a cessation of menses.
(3) Gestational Trophoblastic Disease, a rare tumour that can grow anywhere on or in the body that derives from the cells, which produce the placenta. The sudden stop of menses may indicate such.
Medications and or treatments needed with rationales:
Referral to a specialist ( Obstetrician ) for confirmation of existing pregnancy, further ultrasound scans, and evaluation.
Patient education needed:
Jane needs to know what to do to keep both herself and her child healthy during pregnancy. This should include information on exercise, diet, and avoiding any habits that could harm the baby such as smoking, drinking, and taking certain over the counter medicines.
Referrals for collaborative care needed with rationales:
An Obstetrician should be contacted to develop a more intricate care plan for both the mother and the unborn child.
Conclusion:
After evaluating Jane’s subjective and objective findings, diagnostic or laboratory tests required, identifying differential diagnoses and treatments needed, patient education required, potential referrals for collaboration with other health care providers, it is deduced that an obstetrician will be required to confirm the existing pregnancy and develop a care plan for both the mother and the unborn child. An ultrasound of the pelvis should be conducted to determine the pregnancy stage, and a referral should be made to an Obstetrician. Patient education should be provided regarding healthy pregnancy, exercise, diet, and the avoidance of habits that could harm the baby such as smoking, drinking, and taking certain over the counter medicines.
