For this Assignment, you will select one of the following case studies below. Then, using the case information and best evidence, complete the chart below. Make sure to address all columns in the chart.
Select a case study of interest to you from the listed scenarios below.
Case #1: Jane
Jane is a 42-year-old G4P2103. Jane is divorced and works long, hard hours as a real estate agent. Jane was having irregular and heavy menses for 6 months, and then they abruptly stopped 3 months ago. 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 experiencing breast tenderness. 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. Jane is in disbelief.
Case #2: Natalie
Natalie is a 27-year-old G4P0120. Natalie is married; she and her husband both work two part-time jobs to cover the bills. Natalie presents to your office at about 20 weeks gestation for her initial OB visit. Natalie states she has not been evaluated prior to today for the pregnancy because of lack of funds and ability to get off of work. Natalie also complains of multiple yeast infections during this pregnancy. During your interview with Natalie, you find she has no known medical diagnoses, she is not taking medications, she is a smoker, and she has a negative surgical history. Natalie’s OB history includes two spontaneous losses at 8 and 12 weeks gestation and a loss of a 32 weeks infant following premature rupture of membranes. The 32 week infant was 7 pounds; lived 24 hours; and experienced hypoglycemia, respiratory distress, and sepsis infections. Natalie tells you she waited to seek prenatal care until this point because she did not have enough money to pay for the visit. She and her husband are still paying off medical expenses from the death of their 32 week infant. She tells you that she probably would have waited longer, but she keeps getting these terrible yeast infections. On exam you note a fundal height of 26 weeks and urine dip reveals 1+ leukocytes, 1+ protein, trace blood and 3+ glucose.
Case #3: Katie
Katie is a 17-year-old G1P0. She presents to your office with four missed periods in a row. Katie is a high school student; she is in the 10th grade. She lives with her mother and four siblings. You ask Katie about the father of the baby and she tells you he states “that baby is not mine.” They are not speaking to each other right now. Katie tells you she has been “vomiting a lot and her stomach hurts when she pees.” A urine pregnancy test comes back positive. Katie is so confused because she has been using douching after intercourse as her method of birth control. You ask Katie about the father of the baby, and she tells you he states “that baby is not mine.” They are not speaking to each other right now.
Katie’s past medical history is positive for chlamydia twice in the last year. She was treated at the Health Department but never went back for a follow up. Katie has had no surgeries and is on no medication. When asked, Katie states her last known weight was about 120. Katie’s V/S are BP 110/70, temp 102.5, weight 107. You note enlarged cervical lymph nodes, FHTs are 160, fundal height is 18. Katie’s urine reveals 2+ ketones, 2+ nitrates, and 3+ leukocytes.
Case #4: Sara
Sara is a 32-year-old G1P1001. She presents to your office for a 6-week postpartum check following a normal vaginal delivery of a healthy baby girl. Sara had an 18-hour labor with Pitocin augmentation and delivered a 7 pound 2 oz. girl with a second degree laceration repaired with sutures. Sara spent 2 days in the hospital and was discharged home with her infant and husband. Over the last few weeks, Sara has called the office multiple times with questions about breastfeeding and her sutures healing. Upon walking into the exam room to see Sara, you see her baby in the stroller crying and Sara sitting on the exam table crying into her hands.
Complete the following chart:
MN577 Unit 9 Pregnancy Case Review Chart
Description of the case chosen:
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 three differential diagnoses with rationales
Medications and or treatments needed with rationales
Patient education needed
Referrals for collaborative care needed with rationales
Selected appropriate case from list provided and described case.
Thoroughly outlined all subjective questions that would need to be asked. Thoroughly outlined all objective data and exams to be gathered.
Provided a thorough list of labs and diagnostic tests to be performed with rationale.
Listed three pertinent differential diagnoses with rationales
Thoroughly listed pertinent medications or treatments needed with rationales.
Provided a thorough review of patient education needed and referrals for collaborative care and follow up.
Thoroughly outlined case study in a summary discussing diagnostics, research, or follow up needed.
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.
Before finalizing your work, you should:
be sure to read the Assignment description carefully (as displayed above);
consult the Grading Rubric (under the Course Resources) to make sure you have included everything necessary; and
utilize spelling and grammar check to minimize errors.
Your writing Assignment should:
follow the conventions of Standard English (correct grammar, punctuation, etc.);
be well ordered, logical, and unified, as well as original and insightful;
display superior content, organization, style, and mechanics; and
use APA 6th Edition format.