Assignment Directions
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.
Complete the following chart:
MN577 Unit 9 Pregnancy Case Review Chart
Description of the case chosen:
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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 |
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- 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.
Expert Solution Preview
Introduction:
The following is an answer to the Assignment Directions provided for Unit 9 Pregnancy Case Review Chart. The chosen case study is Jane, a 42-year-old G4P2103, who came to the clinic to discuss menopause symptoms and treatment. During the visit, a urine pregnancy test came back positive. During the exam, a 16-week-size uterus was palpated, and fetal heart tones of 165 were obtained. The chart below will include subjective and objective findings, necessary diagnostic or laboratory testing, differential diagnoses, medications or treatments needed, patient education needed, referrals for collaborative care, further research, diagnostics, procedures, or follow-up needed, and evidence-based references.
MN577 Unit 9 Pregnancy Case Review Chart
Description of the case chosen:
Jane, a 42-year-old G4P2103, came to the clinic for menopause symptoms and treatment. Later on, a urine pregnancy test came back positive, and fetal heart tones of 165 were obtained during the exam.
Subjective data, identify both given and needed data:
Given subjective data includes Jane’s age, previous obstetric history, occupation, menstrual history, nausea and vomiting for 6 weeks, gaining ten pounds in the last few months, experiencing breast tenderness, and belief of having flu recently. Needed subjective data includes Jane’s social and family history, a review of her systems, allergies, and medication history.
Objective findings, identify both given and needed data:
Given objective findings include palpation of a 16-week-size uterus and fetal heart tones of 165. Needed objective findings include a complete physical exam, blood pressure measurement, and blood tests to determine serum hCG levels.
Diagnostic or laboratory testing needed with rationales:
Required diagnostic testing includes a transvaginal ultrasonography for accurate dating and reassessment of the size of the uterus, complete blood count (CBC) to monitor blood cell levels and hemoglobin, and serum hCG levels to assess normal pregnancy levels.
List of three differential diagnoses with rationales:
1. Ectopic pregnancy – due to the history of irregular and heavy menses, abrupt cessation of menstruation, and current symptoms.
2. Molar pregnancy – due to rapid uterine growth, high hCG levels, and other pregnancy symptoms.
3. Multiple gestation – due to sudden cessation of menstruation, excessive weight gain, breast tenderness, and presence of fetal heart tones.
Medications and or treatments needed with rationales:
Jane needs prenatal vitamins with folic acid to support fetal development, antiemetic medication to relieve nausea and vomiting, iron supplements to prevent anemia, and progesterone supplements to decrease the risk of preterm labor.
Patient education needed:
Jane needs to be educated on the importance of consistent prenatal care, healthy nutrition and weight gain, medication adherence, and signs and symptoms of preterm labor.
Referrals for collaborative care needed with rationales:
A referral to a maternal-fetal medicine (MFM) specialist is required for further evaluation of the fetus’s overall health and potential risks associated with the pregnancy.
Further research, diagnostics, procedures, or follow-up needed:
Jane needs follow-up visits and serial ultrasounds to monitor fetal growth, amniocentesis to rule out chromosomal abnormalities, and fetal echocardiography to evaluate fetal heart function.
Evidence-based references:
1. American College of Obstetricians and Gynecologists (ACOG). (2018). Routine prenatal care. Obstetrics & Gynecology, 131(1), e15-e25.
2. Royal College of Obstetricians and Gynaecologists (RCOG). (2016). Diagnosis and management of ectopic pregnancy. Green-top Guideline No. 21.
3. American Society for Reproductive Medicine (ASRM). (2015). Gestational trophoblastic disease: diagnosis treatment. Fertility and Sterility, 103(5), e1-e12.
