NU 661 Assignment 1: Case Study

Sample Answer for NU 661 Assignment 1: Case Study Included After Question

Instructions

Shannon is a return patient who is now 33 weeks pregnant. You will complete her risk assessment table for this assignment.

In this assignment, you will apply the content to patient scenarios.

  • Please view the Shannon Interactive Case. You will notice there are now new visits added below the initial prenatal visit information in the left menu bar of the case. After reviewing the case, you will complete the Week 11 Case Study Worksheet (Word).
  • Save the assignment to your computer, including your name in the title of the document.
  • Please submit your file to this assignment.

Please refer to the Grading Rubric for details on how this activity will be graded.

Shannon Case

Patient Introduction

Shannon is a 35-year-old African American married woman.

History of Present Illness: presents to the office with private insurance with a chief complaint of amenorrhea for 6 weeks. Denies headache, edema, vaginal bleeding or discharge. Patient does have nausea and vomiting for the last week that occurs three times a day. UCG done at home one week ago was positive. Negative urine protein, glucose and nitrates.

  • Allergies: She has no reported allergies.
  • Past Medical History: Past medical history is consistent for infertility; however this pregnancy was achieved spontaneously; HPV, obesity and hypothyroidism.
  • Medications: She takes Valtrex 1 g two tablets by mouth repeated every 12 hours for cold sores and levoxyl 0.125 mg qd.
  • Family Medical History: Family history is consistent for colon cancer – maternal grandfather; diabetes- maternal mother; and hypertension in both the patient’s parents
  • Surgical History: None
  • Gynecology History: Menstrual history: menarche at 12 occurring every 36 days lasting seven days. Menstrual history: menarche at 12 occurring every 36 days lasting seven days.
  • Obstetrics History: The patient did have one pregnancy two years ago that resulted in an early spontaneous miscarriage with no complications.
  • Social History: Patient has been married for seven years and works as a business manager full-time. Social history is negative for tobacco, alcohol, and drugs.

Initial Physical Exam

  • Weight: 258 lbs. Height 65 inches VS 98.4 -84-20-128/74
  • General appearance alert, no acute distress, well hydrated, well developed, obese appearing woman
  • Neuro: oriented to time and place and has appropriate affect and mood.
  • Head: normocephalic, atraumatic.
  • Ears: the Tympanic membranes are intact and clear with normal canals, hearing intact bilaterally.
  • Eyes: normal vision, no discharge, no double vision, blurry vision. Nose: no discharge, inflammation or lesions
  • Mouth: has no deformity or lesions, good dentition, uvula rise midline, tonsils 1+
  • Skin: normal Turgor and color, no rashes, no lesions, no bruising, no edema, normal nails and hair
  • Neck: supple no adenopathy, trachea is midline, no bruits, thyroid normal in size and symmetrical, no nodules palpated
  • Cardiac: 76, regular rhythm, no murmurs or gallops
  • Lungs: no respiratory distress, no use of accessory muscles, lungs are clear to auscultation; symmetrical lung expansion, percussion is resonant throughout
  • Breasts are large and pendulous, symmetrical, nipples are everted, no skin changes, nipple discharge, masses or tenderness; no lymphadenopathy
  • Abdomen: obese, non-distended, non-tender, positive bowel sounds, tympanic throughout, no hepatosplenomegaly noted.
  • External genitalia: normal appearance, normal hair distribution, no lesions or masses
  • Vagina: no lesions, no masses, has adequate pelvic support, the cervix is midline, nullip, with a bluish hue, and no lesions and no cervical motion tenderness
  • Uterus is 6 weeks in size, mobile, non-tender,
  • Adnexa: normal, no masses and non-tender.

Initial Laboratory

  • CBC: Hemoglobin of 13.1, hematocrit 37.6, white blood cell 9.7, red blood cell 4.32, platelets 190,000.
  • Blood type: O positive and negative antibody
  • TSH: 16.76
  • T4: .70
  • Random blood sugar: 102
  • Varicella: immune
  • Rubella: immune
  • RPR: non-reactive
  • Chlamydia: negative
  • Gonorrhea: negative
  • HIV: negative
  • Hepatitis B surface antigen negative; surface antibody positive; Hepatitis C negative
  • Cystic fibrosis: negative
  • Pap within normal limits- negative HPV
  • Urine culture: negative
  • Urinalysis: normal
  • Hemoglobin Electrophoresis: A1 96.3% A2 3.6% F 0.1%

7 week prenatal visit

Shannon returns to the office 1 week later, when she presents with vaginal bleeding x 3 hours, pt. states bleeding started this am, when she got up to go to the bathroom. She reports the bleeding as red, light to moderate in amount. No pain or cramping noted. Weight was 256 lbs. B/P 120/70, negative urine protein, glucose and nitrates; no headache, nausea, vomiting, no edema, vaginal discharge; patient is taking her vitamins.

29 week prenatal visit

Shannon returns for her routine prenatal visit at 29 weeks. Since treating her thyroid condition, she has no further bleeding and the pregnancy has been uneventful. Wgt 254, B/P 122/76, urine is 2+ glucose, trace protein, negative ketones. Shannon indicates that she feels the baby move every day, no leaking, bleeding or contractions. She is taking her PNV qd along with the levoxyl 0.25mg. Shannon indicates that she has some white clumpy vaginal discharge that is very itchy, for the past few days. No odor or burning. Fetal heart is 160, Fundal height is 31 cm

Laboratory: NIPT was normal, AFP 1.60 MoM, Her TSH last visit was 2.4, CBC at 16 weeks was normal, one hour gtt today was 167.

US: Her sequential screen from earlier in the pregnancy is normal.

Fetal Survey at 20 weeks was normal.

33 week prenatal visit

Shannon returns for a routine prenatal visit at 33 weeks. Wgt is 256, B/P 128/80, FHR is 164 and Fundal height is 36 cm. Shannon indicates she feels the baby move every day and performs her kick counts daily. She is taking her PNV and Levoxyl as ordered. She completed the monistat given a few weeks ago, and has no further symptoms. Shannon had an elevated 1 Hour at her 29 week visit and had a 3 hour gtt. Shannon met with the diabetic educator and endocrinologist and was started on NPH 5 units TID. She is doing home blood glucose sticks with a goal of FBS < 90 and 2 hour postprandial of < 120.

Laboratory: 3 hour gtt- FBS 98, 1 hour-164, 2 hour-160, 3 hour 135.

US: Cephalic position, EFW 2812 gr (90%), AFI 21 cm. Posterior fundal grade 2 placenta, 3 vessel cord.

A Sample Answer For the Assignment: NU 661 Assignment 1: Case Study

Title: NU 661 Assignment 1: Case Study

Studies show that approximately 25% of expectant mothers will endure bleeding in the early stages of pregnancy, especially the first trimester (Vandana, 2019). This could result from provoked bleeding, infections, miscarriage, or ectopic pregnancy among others. This paper focuses on the assessment of a 35-year-old African American married woman by the name of Shannon with a chief complaint of amenorrhea for the past 6 weeks.

Subjective Information: From the provided information, the patient presents with a chief complaint of amenorrhea for the past 6 weeks. She however denies discharge, vaginal bleeding, edema, or headache. Her UCG is however positive from a test done last week. She also displayed negative results in urine tests for nitrate, glucose, and proteins. The patient’s past medical history is reported to be consistent for infertility. She however claims to have achieved the current pregnancy spontaneously. She also has a medical history of hypothyroidism, obesity, and HPV. Currently, she is taking drugs such as Valtrex and Levoxyl. The patient also reports a history of one pregnancy two years back which led to an early spontaneous miscarriage without any complications.

The patient denies using any drugs. She is a career woman married for 7 years.  However, during the week 7 prenatal visit, the patient presented with vaginal bleeding for approximately 3 hours with no associated symptoms. During 29th week prenatal visit, her bleeding had stopped, but she presented with white clumpy vaginal discharge that is itchy with no odor or burning sensation. She however displayed no symptoms, with normal pregnancy during her week 33 prenatal visit, while controlling her elevated blood glucose levels.

Objective Information: From the collected lab results, it can be noticed that the patient’s TSH and T4 levels are high above normal limits in pregnancy. Her blood glucose levels are also slightly elevated indicating prediabetes. From her BMI, it can also be noticed that the patient is obese. During her week 7 and week 29 prenatal visit, her vitals still indicated elevated THS and blood sugar levels of which she continued using PNV and Levoxyl as prescribed. The fetal heart rate was however within normal limits but to the higher end of 160. During her 33 weeks of the prenatal visit, the fetal heart rate had elevated to 164, despite the pregnancy still being normal.

Additional Questions

  • What are your thoughts regarding your weight?
  • How is this pregnancy different from the last one?
  • What makes the bleeding stop?
  • And what are some of the physical activities that you enjoy? among others (Brown et al., 2018).

Assessment

  1. Miscarriage: this can be described as the unexpected end of pregnancy before the 20th week of pregnancy. It is associated with cramping and vaginal bleeding among other factors (Mahajan, 2019). The patient in the provided case study displayed vaginal bleeding for the first 6 weeks of pregnancy, with a history of consistent infertility. She also has elevated TSH levels which are associated with a high risk of miscarriage.
  2. Ectopic pregnancy: This is common in the first trimester where the pregnancy forms outside the uterus. The patient will present with abnormal vaginal bleeding, dizziness, low blood pressure, pelvic pain, and rectal pressure (Mahajan, 2019). The patient in the provided case study was positive for abnormal vaginal bleeding but negative for all the other symptoms.
  3. Vasa Previa- occurs when the membrane containing the fatal blood vessels that connect the umbilical cord and placenta overlie are within 2cm from the internal cervical os (Vandana, 2019). It is associated with painless vaginal bleeding, fetal bradycardia, and rupture of membranes. Transvaginal ultrasound is needed to confirm this diagnosis. However, the patient in the provided case study only presented with vaginal bleeding and negative for the other symptoms.

Plan:

What further assessment and/or diagnostic tests would you want to order?

  • Complete blood count (CBC) (Hendriks et al., 2019).
  • Ultrasonography
  • Kleihauer-Betke testing
  • Disseminated intravascular coagulation tests
  • Tests for infections such as UTI, chlamydia, and gonorrhea.

What treatments would you want to order?

  • IV fluid resuscitation, starting with normal saline solution 20mL/kg (Hendriks et al., 2019).
  • Blood transfusion

What education would you provide?

  • The patient should be educated on the importance of being hospitalized so that her fetus can be monitored and treated as needed (Hendriks et al., 2019).

Would you make any referrals to other providers?

  • Obstetrician-Gynecologist (Ob-Gyn)

What would her follow-up be?

  • Closely monitored after every 2 hours until she is discharged.

References

‌Brown, D. L., Packard, A., Maturen, K. E., Deshmukh, S. P., Dudiak, K. M., Henrichsen, T. L., … & Glanc, P. (2018). ACR Appropriateness Criteria® first trimester vaginal bleeding. Journal of the American College of Radiology15(5), S69-S77. https://doi.org/10.1016/j.jacr.2018.03.018

Hendriks, E., MacNaughton, H., & MacKenzie, M. C. (2019). First trimester bleeding: evaluation and management. American family physician99(3), 166-174. PMID: 30702252

Mahajan, M. (2019). Ultrasonographic Evaluation of First Trimester Bleeding and its Clinical Assessment: A Prospective Study. Journal of Medical Science and Clinical Research7(6). https://doi.org/10.18535/jmscr/v7i6.22

Vandana, J. (2019). Need of Sonography in Vaginal Bleeding in Early Pregnancy; As a Primary Investigation. Journal of Medical Science and Clinical Research7(12). https://doi.org/10.18535/jmscr/v7i12.52