Obstetric Case Study Assignment
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
Obstetrics Case Study Template
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.
| What is her gravidity and parity? | |
| Use Nagel’s Rule to calculate her EDC. | |
| Write an assessment statement from this visit.
Outline at least 7 components. |
|
| Write a plan for this visit.
Outline at least 7 components. |
References