Pregnancy :Obstetric Case Study Assignment

Obstetric Case Study Assignment

Pregnancy

Jania, a 26-year-old single Hispanic woman presents for an appointment after a positive home pregnancy test. She states that this is a planned pregnancy. She is very sure that the first day of her last menstrual period was June 29th (assume today is August 22nd). She has experienced fatigue, daily nausea, urinary frequency, and nipple tenderness the past few weeks. She denies any vaginal bleeding. Her history includes:

Medications: albuterol inhaler prn, women\’s One a Day vitamin

Allergies: sensitivity to latex

PMH: she has asthma, diagnosed as a teenager. She uses a rescue inhaler approximately once weekly, mostly with exercise. She notes \”occasional\” constipation, affecting her \”about once a week\”.

PGYN/OBH: menarche age 13, regular every 28-30 days lasting 4 days, minimal cramping. She had an elective termination of pregnancy at age 16, a spontaneous abortion at 18, and gave birth vaginally to a full-term male 8 lb 7 oz at age 20, which she subsequently placed for adoption. She had a Paragard IUD placed postpartum and had that removed 6 months ago. Last annual exam was 2 years ago, Pap was done at that time and was negative.

PSH: she had her wisdom teeth surgically removed as a teen, as well as her appendix. She was diagnosed with scoliosis in her teens and had Harrington rods inserted.

FH: father 52 has had a coronary stent placed; mother 54 was diagnosed with Type 2 DM 4 years ago and is well controlled. Sisters, 3 (27, 24, and 22) are all healthy. Her 27-year-old sister had a child born at 32 weeks gestation, who was born with a cleft palate. Her 24-year-old sister has had a LEEP procedure for cervical dysplasia. Her 22-year-old sister has developmental delays. Paternal grandparents are deceased; maternal grandmother w/ endometrial cancer and subsequent hysterectomy 20 years ago. Maternal grandfather with TIAs.

SH: has been in a relationship w/ current partner x 2 years. They have \”taken breaks a few times\”; currently Jania lives alone, works as a nurse at a long-term care facility. She occasionally smoked marijuana prior to pregnancy, not since; denies ETOH, substance use. Drinks 2 cups of coffee, 2 diet colas per day. Eats vegetables and fruits \”1-2 servings total of both per day\”; otherwise diet is largely typical American diet w/ fast food 2-3 times weekly. Drinks \”maybe 4 glasses of water\” per day Walks dog daily around the block for exercise. Also has a house cat.

Immunizations/childhood illnesses: had varicella as a child; immunizations all UTD.

ROS: negative except for those things mentioned already

Physical Exam

VS: BP: 116/73 (sitting), P: 89, RR: 18, T: 36.7 Ht: 63 inches Wt: 152 lbs (states that is close to her usual weight).

General: Awake, alert and oriented. No acute distress. Well developed, hydrated and nourished. Appears stated age.

Skin: Skin is warm, dry and intact without rashes or lesions. Appropriate color for ethnicity. Nail Beds pink with no cyanosis or clubbing.

Head: The head is normocephalic and atraumatic without tenderness, visible or palpable masses, depressions, or scarring. Hair is of normal texture and evenly distributed.

Eyes: Conjunctivae are clear without exudates or hemorrhage. Sclera is non-icteric. EOM are intact, PERRLA. Eyelids are normal in appearance without swelling or lesions.

Ears: The external ear and ear canal are non-tender and without edema. The canal is clear without discharge. The tympanic membrane is normal in appearance.

Nose: Nasal mucosa is pink and moist. The nasal septum is midline. Nares are patent bilaterally.

Throat: Oral mucosa is pink and moist with good dentition. Tongue normal in appearance without lesions and with good symmetrical movement. No buccal nodules or lesions are noted. The pharynx is normal in appearance without tonsillar edema or exudates.

Neck: The neck is supple without adenopathy. Trachea is midline. Thyroid gland is normal without masses. Carotid pulse 2+ bilaterally without bruit. No JVD.

Cardiac: The external chest is normal in appearance without lifts, heaves, or thrills. PMI is not visible and is palpated in the 5th intercostal space at the midclavicular line. Heart rate and rhythm are normal. No murmurs, gallops, or rubs are auscultated. S1 and S2 are heard and are of normal intensity.

Respiratory: The chest wall is symmetric and without deformity. No signs of trauma. Chest wall is non-tender. No signs of respiratory distress. Lung sounds are clear in all lobes bilaterally without rales, ronchi, or wheezes. Resonance is normal upon percussion of all lung fields.

Abdominal: Abdomen is soft, symmetric, and non-tender without distention. There are no visible lesions or scars. The aorta is midline without bruit or visible pulsation. Umbilicus is midline without herniation. Bowel sounds are present and normoactive in all four quadrants. No masses, hepatomegaly, or splenomegaly are noted.

Genital/Rectal: Rectal exam is deferred. No external masses or lesions.

External genitalia is normal in appearance without lesions, edema, masses or tenderness. Vagina is pink and moist without lesions or discharge; walls are well rugated. Cervix is non-tender without lesions or erosion. Small amount of homogenous, non-malodorous white discharge on the walls and in the vault. Uterus is anteflexed, non-tender and 8 week gestation size. Ovaries are non-tender without palpable masses or enlargement.

Spine: Neck and back are without deformity, external skin changes, or signs of trauma. Posture is upright, gait is smooth, steady, and within normal limits.

No tenderness noted on palpation of the spinous processes. Spinous processes are midline. Cervical, thoracic, and lumbar paraspinal muscles are not tender and are without spasm.

No discomfort is noted with flexion, extension, and side-to-side rotation of the cervical spine, full range of motion is noted. Full range of motion including flexion, extension, and side-to-side rotation of the thoracic and lumbar spine are noted and without discomfort.

Straight leg raise test is negative bilaterally. Sensation to the upper and lower extremities is normal bilaterally. No clonus is noted. Grip strength is normal bilaterally. Dorsi/plantar flexion is normal bilaterally.

Extremities: Upper and lower extremities are atraumatic in appearance without tenderness or deformity. No edema or erythema. Full range of motion is noted to all joints. Muscle strength is 5/5 bilaterally. Tendon function is normal. Capillary refill is less than 3 seconds in all extremities. Pulses palpable.

Neurological: The patient is awake, alert and oriented to person, place, and time with normal speech. Motor function is normal with muscle strength 5/5 bilaterally to upper and lower extremities. Sensation is intact bilaterally. Reflexes 2+ bilaterally. Cranial nerves are intact.

Psychiatric: Appropriate mood and affect. Good judgment and insight. No visual or auditory hallucinations. No suicidal or homicidal ideation.

Questions

1) What is her gravidity and parity?

2) Calculate her EDC using Nagel’s Rule.

3) Write an assessment statement from this visit. Outline at least 7 components.

4) Write a plan for this visit. Outline at least 7 components.

Must be in APA style, and Uptodate articles, and American Guidelines. Thanks

Assignment Directions: The student will read the case study and fill out the provided template. This should be filled out as if the student were writing a SOAP note. The use of proper medical terminology is expected. The student will use at least 3 references to support their care plan. The student is expected to follow APA formatting guidelines and complete a reference list on page 2 of the template.

Solution

Obstetrics Case Study Template

 

What is her gravidity and parity?	Gravida 4; Para 1     Gravidity and parity are two common terms in obstetrics that healthcare providers need to know. Wakana et al. (2021) define gravidity as the number of times that a woman has conceived. The authors further define parity as the number of times that a woman has given birth to a fetus at or beyond 24 weeks gestational period, irrespective of whether it was a live or a stillbirth.   The case study describes a woman called Jania. Jania is a 26-year-old single Hispanic woman who has presented for an appointment after a positive home pregnancy test. Past obstetrics history indicates that her gravidity is 4, written as Gravida 4. Jania is currently pregnant. In addition, she had an elective termination of pregnancy at age 16, a spontaneous abortion at 18, and gave birth vaginally to a full-term male 8 lb 7 oz at age 20, which she subsequently placed for adoption. Jania has a parity of 1. She will become para 2 if her current pregnancy reaches 24 weeks.
Use Nagel’s Rule to calculate her EDC.	Naegele’s Rule is a 3-step method that is normally used to calculate the estimated due date of delivery (Johns Hopkins Medicine, 2021). In Jania’s case;   Step 1: The first day of her last menstrual period was June 29th 2021.   Step 2: Counting back 3 calendar months gets to March 29th 2021.   Step 3: Adding 1 year and 7 days to the date gives 5th April 2022.   From the above calculation, Jania’s expected delivery date is 5th April 2022.
Write an assessment statement from this visit. Outline at least 7 components.	Jania’s chief complaint is that she is pregnant and has experienced fatigue, daily nausea, urinary frequency, and nipple tenderness the past few weeks. She denies any vaginal bleeding. Her assessment statement includes the following 7 components;   Jania’s fatigue might be as a result of reduced blood sugar levels and other nutrients owing to the fact that her body is sharing nutrients with the developing fetus. She might be suffering from gestational diabetes that is normally characterized by fatigue, daily nausea, and increased urinary frequency. Jania is asthmatic and needs guidance on how to avoid respiratory problems throughout the pregnancy period. Since Jania is a single mother who lives alone, she is likely to experience depression and anxiety during pregnancy. She needs to be close to someone who can offer assistance when needed during pregnancy. Jania has a history of scoliosis which limits her ability to perform heavy tasks and engage in difficult exercises. She is at increased risk of developing vaginal bacterial infections due to her pregnancy status.
Write a plan for this visit. Outline at least 7 components.	A plan of care for Jania should address 7 components highlighted in her assessment statement above. The healthcare provider will; Advice Jania to increase the portion of food that she has been consuming per meal to meet her bodily needs as well as that of the fetus. She should eat a balanced diet that includes carbohydrates, fibers, fruits, vegetables, proteins, dairy products, and healthy fats (Jouanne et al., 2021). Perform an oral glucose tolerance test (OGTT) to establish whether Jania has gestational diabetes mellitus (American Diabetes Association, 2020). Educate Jania to adhere to the prescribed asthma medications to avoid suffering related complication during pregnancy (Zaeh et al., 2021). Refer her to a mental health professional for further psychological evaluation. Establish connections between Jania and her family and friends and advise her to consider staying with a helper at home who can offer assistance at any time. Refer Jania to a neurologist to assess her status regarding scoliosis. The neurologist should work in collaboration with a physiotherapist to offer advice regarding appropriate exercises and physical activities she can engage in during pregnancy (Fishman, 2021). Help her to understand her vulnerability to infections at this time and educate her to avoid having unprotected sex with multiple partners to reduce her risk of developing bacterial vaginosis (Chen et al., 2021).

 

References

American Diabetes Association. (2020). Classification and Diagnosis of Diabetes: Standards of Medical Care in Diabetes—2020. Diabetes Care, 43(Supplement 1): S14-S31. https://doi.org/10.2337/dc20-S002

Chen, X., Lu, Y., Chen, T., & Li, R. (2021). The female vaginal microbiome in health and bacterial vaginosis. Frontiers in Cellular and Infection Microbiology, 11, 631972. https://doi.org/10.3389/fcimb.2021.631972

Fishman, L. M. (2021). Isometric yoga-like maneuvers improve adolescent idiopathic scoliosis-a nonrandomized control trial. Global Advances in Health and Medicine, 10, 2164956120988259. https://doi.org/10.1177/2164956120988259

Johns Hopkins Medicine. (2021). Health: Calculating a due date. https://www.hopkinsmedicine.org/health/wellness-and-prevention/calculating-a-due-date

Jouanne, M., Oddoux, S., Noël, A., & Voisin-Chiret, A. S. (2021). Nutrient requirements during pregnancy and lactation. Nutrients, 13(2), 692. https://doi.org/10.3390/nu13020692

Wakana^, S., Kyoko^, N., Azusa_, S., Michihiro, S., Megumi, T., Ryusuke, I., Kei, A., Masahiro^, K., Hirohito, M., Yuuki, K., Yukako, T., Takuo, H., Takahisa, M., Atsushi, H., Hiroyuki, W., Yutaka, I., & Takayoshi, O. (2021). Association of parity and gravidity with carotid intima-media thickness: The Ohasama study. Journal of Hypertension, 39(p), e157 doi:10.1097/01.hjh.0000746104.56639.84

Zaeh, S. E., Lu, M. A., Blake, K. V., Ruvalcaba, E., Ayensu-Asiedu, C., Wise, R. A., Holbrook, J. T., & Eakin, M. N. (2021). “It is kind of like a responsibility thing”: transitional challenges in asthma medication adherence among adolescents and young adults. The Journal of Asthma, 1, 1-11. doi: 10.1080/02770903.2021.1897836. Epub ahead of print. PMID: 33653199; PMCID: PMC8458468.