iHuman Case Study – Pamela FlowersiHuman Case Study – Pamela Flowers
Discuss the questions that would be important to include when interviewing a
... [Show More] patient with this issue.
It is important to ask the patient questions that provide more information about the possible diagnosis as well as help you focus your findings or rule out other diagnosis and thus provide treatment in a timely manner. Some questions I would ask the patient are: the onset and duration of the pain because acute pain is often times intense and generally characterized as being sudden in onset, sharp in nature, and short in duration (Schuiling & Likis, 2016). In addition, acute pelvic pain is often associated with an identifiable cause such as PID or ectopic pregnancy (Schuiling & Likis, 2016).I would ask the patient to describe location of the pain and if the pain was deep or shallow because superficial pain occurs when the body surface is stimulated, whereas deep pain originates in muscles, joints, bones, or connective tissue(Schuiling & Likis, 2016.
Describe the clinical findings that may be present in a patient with this issue.
Some examples of clinical findings in a patient with ectopic pregnancy are acute pelvic pain and history of pelvic inflammatory disease. According to Schuiling & Likis (2016), acute pelvic pain is often caused by an identifiable cause such as PID or ectopic pregnancy, a wrong diagnosis of acute pelvic pain can lead to serious sequelae, such as impaired fertility, rupture of an ectopic pregnancy or a hemorrhagic ovarian cyst, and even death. Another clinical finding of ectopic pregnancy is unilateral cramping pain that is continuous. Also, patients with ectopic pregnancy will often present with vaginal bleeding as well (Schuiling & Likis, 2016). So, the triad of ectopic pregnancy are missed menstrual period, unilateral and severe left lower quadrant pelvic pain, and abnormal vaginal bleeding.
Are there any diagnostic studies that should be ordered on this patient? Why?
Complete blood count (CBC), Blood type and screen, Erythrocyte sedimentation rate (ESR), Serologic testing for syphilis, Urinalysis and urine culture (where appropriate), Pregnancy testing (if appropriate), Vaginal smears or cultures to rule out infection, Stool guaiac to evaluate gastrointestinal pathology, Thyroid-stimulating hormone (TSH) are all important test to r/o the cause of the pelvic pain (Schuiling & Likis, 2016). The erythrocyte sedimentation rate, and white blood count are usually elevated, and serum beta hcg would be positive. A transvaginal ultrasound is a gold standard for diagnosis of ectopic pregnancy (Schuiling & Likis, 2016).
List the primary diagnosis and three differential diagnoses for this patient. Explain your reasoning for each.
The primary diagnosis is ectopic pregnancy due to indications for the triad of ectopic pregnancy: missed menstrual period, unilateral and severe left lower quadrant pelvic pain, and abnormal vaginal bleeding. An obstetric ultrasound that shows a left adnexal mass with an echogenic ring that is separate from the left ovary and a positive human chorionic gonadotropin (hCG) plasma level are definitive for ectopic pregnancy (Schuiling & Likis, 2016). The three differential diagnosis are:
1. Tubo-ovarian abscess because it is a direct complication of pelvic inflammatory disease with symptoms such as diffuse lower abdominal pain and pelvic pain, abdominal distension, and fever and chills (Schuiling & Likis, 2016).
2. Ovarian cyst is often associated with unilateral pelvic pain that radiates to lower back and thighs, menstrual irregularities, dyspareunia, and exacerbation of pain with other physical activity (Schuiling & Likis, 2016).
3. Abortion that is spontaneous can often result in vaginal bleeding, crampy pelvic pain, preceding or present symptoms of pregnancy (Schuiling & Likis, 2016).
Reference
Schuiling, K. D. & Likis, F. E. (2016). Women’s Gynecologic Health (3rd ed.). Sudbury, MA: Jones & Bartlett. ISBN: 9781284076028
iHuman Case Study – Pamela Flowers
Pamela Flowers is a 24-year-old presenting with a chief complaint of vaginal bleeding and pelvic pain for the past 24 hours.
• Discuss the questions that would be important to include when interviewing a patient with this issue.
• What are the events surrounding the start of your abnormal vaginal bleeding?
• Do you have any other symptoms associated with your abnormal vaginal bleeding?
• How severe is your abnormal vaginal bleeding?
• Have you had abnormal vaginal bleeding like this before?
• Do you have any menstrual irregularities?
• Do you have bleeding between your menstrual cycles?
• Have you recently missed or stopped taking your birth control or hormone pills?
• When did your last period begin?
• How severe (1-10 scale) is your pelvic pain?
• When and what was the result of your last gynecological exam?
• Is it possible that you are pregnant?
• Have you had a previous ectopic pregnancy, abortion, miscarriage, uterine surgery, pelvic inflammatory disease, history of STD/STI’s, and/or history of fibroids?
In addition to gathering information based on your chief complaint, it is important to ask about past medical history, prior surgeries/hospitalizations, prescription and over the counter medications (Schuiling & Likis, 2016).
• Describe the clinical findings that may be present in a patient with this issue.
Clinical assessment findings of ectopic pregnancy include spotting, vaginal bleeding, dizziness, pelvic and/or abdominal pain (Buttaro, Trybulski, Polgar-Bailey, & Sandberg-Cook, 2017). Patients often present with complaints of a unilateral pelvic pain that is cramping or sharp (Buttaro et al., 2017). The nurse practitioner (NP) may find that on physical examination with a speculum there is a Chadwick’s sign, a bluish color of the cervix, possible uterine enlargement, abdominal tenderness with guarding and possible cervical motion tenderness (Buttaro et al., 2017).
• Are there any diagnostic studies that should be ordered on this patient? Why?
• Human chorionic gonadotropin (HCG) serum to check for pregnancy along with a plateau or fall in the titer which is indicative of an ectopic pregnancy or miscarriage (Buttaro et al., 2017).
• Complete blood count (CBC) because of the correlation of ectopic pregnancies and anemia (Buttaro et al., 2017).
• Transvaginal Ultrasound is the best diagnostic tool to adequately provide imaging of a viable pregnancy or ectopic pregnancy (Buttaro et al., 2017).
• List the primary diagnosis and three differential diagnoses for this patient. Explain your reasoning for each.
The primary diagnosis for Ms. Flowers is ectopic pregnancy. Her clinical presentation of amenorrhea, pelvic/LLQ pain, and abnormal vaginal bleeding are considered the triad classical findings (Buttaro et al., 2017). According to Sivalingam, Duncan, Kirk, Shephard, & Horne (2011), the most common symptoms of ectopic pregnancy include pelvic pain and vaginal bleeding which usually occurs 6 to 10 weeks gestation. Ms. Flowers obstetric ultrasound revealed no evidence of an intrauterine gestation, however showed a left adnexal mass with an echogenic ring suggesting an ectopic pregnancy. Confirmation of this diagnosis is also supported with her serum HCG results of 1002 suggesting a 6-week pregnancy.
Differential Dx:
• Pelvic inflammatory Disease (PID): I included this diagnosis because of her complaints of pelvic pain, her age, inconsistent use of condoms and previous history of chlamydia. This was ruled out with the ultrasound and her WBC’s were within a normal range at 8000.
• Ovarian cyst: This is often associated with menstrual irregularities and unilateral pelvic pain that correlate with Ms. Flowers symptoms. This was also ruled out with her ultrasound.
• Spontaneous abortion (miscarriage): Ms. Flowers confirmation of pregnancy, presenting symptoms of vaginal bleeding and cramping pelvic pain warrant an inclusion of miscarriage. Again, this diagnosis was ruled out because of the results of the ultrasound which showed no evidence of intrauterine gestation.
• Discuss your management plan for this patient, including pharmacologic therapies, tests, patient education, referrals, and follow-ups.
The NP must first assess the patients risk of tubal rupture prior to determining an appropriate therapy (Buttaro et al., 2017). The treatment plan for Ms. Flowers includes pharmacological management with Methotrexate (1 mg/kg or 50 mg/m2) given intramuscularly for an ectopic mass less than 3 to 4cm for early unruptured ectopic pregnancies (Buttaro et al., 2017). An intensive close follow up for women who meet the following criteria: (1) hCG <1500 (2) mild clinical symptoms (3) small nonviable tubal ectopic pregnancy along with no or little intra-abdominal bleeding includes serial hCG measurements, initially every 2 days and then weekly, until the hCG drops below 2 IU/L (Buttaro et al., 2017). The inclusion criteria for Methotrexate also includes hemodynamically stable, no fetal heart activity or clear yolk sac in adnexal mass, patient’s preference of a medical option, no medical conditions such as renal or liver disease and finally willing to attend follow-up for up to 6 weeks (Sivalingam et al., 2011).
Surgical management involving laparoscopy may be warranted in the event of an ectopic mass rupture (Sivalingam et al., 2011). Finally, it is important to administer RhoGAM to Rh negative mothers (Buttaro et al., 2017). Patient education regarding Methotrexate including avoiding another pregnancy for at least 3 months due to the teratogenic effects of this drug.
References
Buttaro, T., Trybulski, J., Polgar-Bailey, P., & Sandberg-Cook, J. (2017). Primary Care: A Collaborative Practice (5th ed.). St. Louis, MO: Elsevier.
Hawkins, J., Roberto-Nicholas, D. & Stanley-Haney, J. (2016). Guidelines for Nurse Practitioners in Gynecologic Settings (11th ed.). New York, NY: Springer Publishing.
Schuiling, K. D. & Likis, F. E. (2016). Women's gynecologic health (3rd ed.). Sudbury, MA: Jones & Bartlett.
Sivalingam, V. N., Duncan, W. C., Kirk, E., Shephard, L. A., & Horne, A. W. (2011). Diagnosis and management of ectopic pregnancy. Journal of Family Planning and Reproductive Health Care, 37(4), 231–240. doi: 10.1136/jfprhc-2011-0073 [Show Less]