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Nursing > Exam > Tina Sandler Part 1 OBGYN(Graded A+) (All)
Tina Sandler Part 1 OBGYN(Graded A+)
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History • How can I help you today • Do you have any other symptoms or concerns we should discuss • When did you last period begin • Do you drink alcohol? If so what do you drink • Do you use any rec. drugs • Tell me about your diet, what you normally eat • All ROS: all body system questions • How severe is your nausea • How often are you nauseous • Does anything make your nausea and/or vomiting better or worse • Every been hospitalized • Taking prescription meds? • OTC meds? • How long do your periods last • What treatments have you had for your nausea and/or vomiting • Do you have any pain or other symptoms associated with your constipation • How severe is your constipation • When did the constipation start • How often do you have problems with constipation • What treatments have you had for your constipation • Do you have any other symptoms associated with your fatigue/tiredness • Does anything make your fatigue better or worse • When did your fatigue/tiredness start • Do you have HIV • Are you using any form of birth control Physical • Pulse 60 • BP 120/60 • RR 12 • Mental AOx4 • Auscultate lungs • Auscultate heart • Auscultate abd • Inspect skin overall • Visual inspection of extremitites • Palpate extremities • Breast exam • Visually inspect abd • Palpate abd • Fetal heart tones • Genitourinary exam female • Mini-mental state exam Expert FINDINGS on physical • Pregnant by home test (MSAP) • Nausea, no vomiting (related) • Mild constipation (related) • Fatigue (related) • Hx. PIH and hemorrhage (resolved) • Hx. Of fetal loss (resolved) Problem Statement • Tina Sandler is a G4P2111, 29 year old female who presents to the clinic after having a missed period and positive home pregnancy test. She has 2-months of intermittent nausea without vomiting, fatigue and mild constipation. She had 4 past pregnancies. One child, who is 4 years old, was an uncomplicated pregnancy and vaginal delivery. Three years ago, she has an IUFD at 37 weeks gestation. That pregnancy was complicated by antenatal gestational hypertension. Two years ago, she has a preterm delivery at 26 5/7 weeks gestation due to worsening pre-eclampsia. One year ago today she has an ectopic pregnancy that was treated with methotrexate. Select body systems that are most likely to be the source of primary pathology • Cardiovascular • Integumentary • Genitourinary/renal • Psychologic • Sexual/reproductive Differential diagnosis • Pregnancy (Lead, MnM) • Ectopic Pregnancy (Alt, MnM) Test/Diagnosis • hCG urine • Blood type and screen • HIV • RPR • Rubella • BG • Urine culture • Coombs test, indirect • Neisseria gonorrhoeae, swab PCR • HBsAg • STDs • Pap smear • Chlamydia, swab PCR • Obstetric ultrasound • TSH • UA • CBC Diagnosis • Pregnancy Plan • App soap note if you want. I didn’t • Plan o Prenatal vitamins o Supportive care for nausea- to notify clinic if increased problems o Supportive care for occasional constipation- increase fluid, fiber in diet and exercise. o Please sign up for childbirth classes at available clinic o Counsel for manner of delivery o Inform patient on impact of alcohol, drug, tobacco, domestic violence, depression and environmental exposures in early pregnancy o Advise her to take a daily multivitamin containing 0.4 mg folate o Counsel on the importance of oral health and routine dentist visits o RTCfor appointment in 4 weeks Show Less
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