explain how you might think differently about the types of tests or treatment options your colleagues suggested and why.
explain how you might think differently about the types of tests or treatment options your colleagues suggested and why.
Respond to at least two of your colleagues’ posts on two different days and explain how you might think differently about the types of tests or treatment options your colleagues suggested and why. Use your learning resources and/or evidence from the literature to support your position. Respond to the SOAP note below
Patient Information:
P.H., 29 y.o., Female, African American
S.
CC (chief complaint): Patient present because of a positive home test.
HPI: P.H. is a 29 y.o African American female presenting to the clinic today with a positive home pregnancy test. Pt states her LMP was 04/04/2022. She reports breast tenderness, fatigue, and nausea (which is what made her suspect she was pregnant). Pt denies any other complaints today.
Current Medications:
Over-the-counter women’s gummy vitamins
Allergies:
No known allergies
PMHx:
Gestational Diabetes week 39, 4/2014, and week 38 7/2017
Soc & Substance Hx:
P.H. is a warehouse supervisor at Amazon and works 36 hrs. per week. She and her fiancé have been together for 5 years, and he works in an accounting office. They live in a 3-bedroom townhouse within easy walking distance to schools and stores. Her fiancé’s parents live in the same complex they do, and her parents and younger sister live about a mile away. She has the support of her fiancé’s family as well as hers. She has become a vegetarian since her last pregnancy. She denies texting and driving. She utilizes seatbelts whether driving or being a passenger. Denies smoking, alcohol, and recreational drug use.
Fam Hx:
No family history given
Surgical Hx:
No surgical history
Mental Hx:
No mental health history
Violence Hx:
No concerns or issues
Reproductive Hx:
LMP: 4/4/22, G:6 T:2 P:1 A:2 L:3. She is sexual only with her fiancé’. No contraceptive uses.
GYN Hx:
1st menses age 12, menses every 28 days and lasting 5 days. Her pap and STD history is negative
ROS:
GENERAL: Repots fatigue, No weight loss, fever, chills,
HEENT: Eyes: No visual loss, blurred vision, double vision, or yellow sclerae. Ears, Nose, Throat: No hearing loss, sneezing, congestion, runny nose, or sore throat.
CARDIOVASCULAR: No chest pain, chest pressure, or chest discomfort. No palpitations or edema.
RESPIRATORY: No shortness of breath, cough, or sputum.
GASTROINTESTINAL: Reports nausea, No anorexia, vomiting, or diarrhea. No abdominal pain or blood.
NEUROLOGICAL: No headache, dizziness, syncope, paralysis, ataxia, numbness, or tingling in the extremities. No change in bowel or bladder control.
MUSCULOSKELETAL: No muscle pain, back pain, joint pain, or stiffness.
HEMATOLOGIC: No anemia, bleeding, or bruising.
GENITOURINARY/REPRODUCTIVE: Denies burning on urination. Reports positive pregnancy test. LMP: 04/04/2022. Reports breast tenderness. No reports of vaginal discharge, or pain. sexually active with fiancé’
O.
General: Vital signs height 5’4” weight 176 lbs. and her BP is 112/68
HEENT: No head trauma, no hearing loss, pt. wears glasses, no drainage from nostrils lymph nodes normal, throat clear
LUNG clear to auscultation, no wheezing or difficulty breathing
CV: regular sinus rhythms without murmur or gallop
ABD: soft, non-tender,
BREASTS: tender, no masses, dimpling, redness, or discharge,
VVBSU: WNL
CERVIX: Soft and tender
UTERUS: Mid-mobile, non-tender
ADNEXA: No masses or tenderness
RECTUM: No lesion or sores
Diagnostic results:
- Urine test: Urinary tests present antibodies against hCGβcf. In urine, hCG appearance and rise show similar patterns to those observed in maternal circulation. hCG is a hormone produced primarily by syncytiotrophoblastic cells of the placenta during pregnancy and it stimulates the production of progesterone by maintaining the corpus luteum, which, prevents menstruation (Padoan, 2020).
- Blood test: Your blood can detect the presence of hCG so a blood test can be done as well to determine pregnancy. They can detect hCG faster than a urine test. According to Stickler (2017), there are two types of blood tests. One is the Qualitative hCG blood test: This test checks to see whether any hCG is being produced in the body. It gives a simple yes or no answer as to whether you’re pregnant. Quantitative hCG blood test: This test measures the specific level of hCG in the blood. The quantitative is very accurate (Stickler, 2017).
- Ultrasonography: It is a scan that uses high-frequency sound waves to capture live images from the inside of your body. It’s also known as sonography. Used to confirm and date the pregnancy (Cherney et al., 2019).
A.
- Early pregnancy: This patient most likely is experiencing early pregnancy. She stated that the symptoms that she is experiencing she has experienced before. Signs of pregnancy are fatigue, tender breast, nausea, vomiting, and positive pregnancy test (What Are Some Common Signs of Pregnancy? 2017).
- Ectopic Pregnancy: Ectopic pregnancy occurs when a developing embryo implants itself at a site other than the endometrium of the uterine cavity, most commonly within the fallopian tube. Expectant management of ectopic pregnancy involves allowing the pregnancy to take its natural course with close physician follow-up until there is the clinical resolution of symptoms, a negative urine pregnancy test, or negative serum b-hCG (Ranchal & Dunne, 2021)/
- Pregnancy Loss (Spontaneous Abortion): The patient does have a history of pregnancy loss. During early pregnancy, the uterus is remarkably well protected from blunt trauma to the maternal abdomen; therefore, trauma does not represent a significant risk for miscarriage. This can rule out after completing a blood test or ultrasonography (Walter & Alvarado, 2018).
P.
The diagnosis that I chose is early pregnancy. The patient has a positive home pregnancy test, which will be confirmed by another urine test or blood test. She is experiencing pregnancy symptoms such as nausea, fatigue, and tender breast. The other diagnosis has other symptoms that the patient is not exhibiting currently. We do have to ensure that proper testing is done to rule out the other diagnosis. As if it is an ectopic pregnancy or pregnancy loss, we want to ensure that the patient is getting the proper care.
The plan would be to confirm pregnancy. Then prescribed her the necessary medications such as folic acid and prenatal vitamins. The patient will need to follow a proper diet as she does have a history of gestational diabetes, so we want to be on the lookout for that. Advice the patient to monitor her blood pressure at home and report any signs or symptoms of high blood pressure to her obstetrician. Schedule monthly appointments with an obstetrician. Avoid smoking, alcohol, and recreational drug use. Ensure patient has proper vaccinations such as COVID19. Educated the patient on pregnancy even though she had been pregnant before. When seeing an obstetrician ensure a thorough health history is completed to include known genetic and family history.
References
Cherney, K., Kathyrn, Watson, & Lamoreux, K. (2019, February 28). What Do You Want to Know About Pregnancy? Healthline. https://www.healthline.com/health/pregnancy
Padoan, A. (2020). Laboratory tests to monitor physiological pregnancy. Journal of Laboratory and Precision Medicine, 5, 7–7. https://doi.org/10.21037/jlpm.2019.12.02
Stickler, T. (2017, January 27). Tests Used to Confirm Pregnancy. Healthline. https://www.healthline.com/health/pregnancy/tests
Ranchal, S., & Dunne, C. (2021). Diagnosis and treatment of ectopic pregnancy: Early diagnosis of ectopic pregnancy is critical to reducing maternal mortality and improving treatment success rates, especially since many women have no identifiable risk factors. British Columbia Medical Journal, 63(3), 112–116.
What are some common signs of pregnancy? (2017, January 31). National Institute of Child Health and Human Development. https://www.nichd.nih.gov/health/topics/pregnancy/conditioninfo/signs#
Walter, M. A., & Alvarado, M. S. (2018). Clinical aspects of miscarriage. MCN: The American Journal of Maternal/Child Nursing, 43(1), 6–12. https://doi.org/10.1097/nmc.0000000000000390
Requirements: Respond to the SOAP note | .doc file
Masters Health & Medical
Respond to the SOAP note provided
Respond to at least two of your colleagues’ posts on two different days and explain how you might think differently about the types of tests or treatment options your colleagues suggested and why. Use your learning resources and/or evidence from the literature to support your position.
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