Ms. Smith is a 34-year-old Caucasian female who presented at the office for her first prenatal appointment. Ms. Smith lives in Palm Beach County and maintains a full-time accounting position. She complains of nausea that occurs particularly in the morning and subsides by 10 am for the past two (2) weeks. However, this nausea has not subsided for three (3) days. Ms. Smith is usually active but has noticed experiencing greater fatigue at the end of the day. She has reported no vaginal bleeding or fetal movement. Her last menstruation was on October 25, 2015. The patient believes she is 12 weeks and took a home pregnancy test which was positive. She denies experiencing abdominal pain, chest pain, diarrhea, shortness of breath, or dizziness.
Past medical history of the patient includes an ectopic pregnancy and surgery both occurring in 2014. Currently, the patient is maintaining prenatal vitamins and supplements. She lives with her husband and their 7-year-old daughter. Aside from working as a full-time accountant, Ms. Smith is working to finish a degree in nursing and takes one to two classes per semester. She denies smoking, drinking alcohol, or using any illegal drugs. She is sexually active and maintains sexual relation with only her husband. She also states that she feels safe at home.
The medical history of the patient’s family was also recorded. The patient maintains no contact with her father and her paternal grandparents, so their medical history remains unknown. Her mother, on the other hand, has hypertension which is managed through medications. Her maternal grandfather is 79 years of age with a history of diabetes and stroke. Her maternal grandmother is also 79 years old with a history rheumatoid arthritis.
The patient denies fatigue, fever, chills and night sweats but admits experiencing decreased energy level. She also denies delayed healing, rashes, bruises, bleeding, skin discolorations, and any changes in moles or lesions. The patient also denies sinus problems, dysphagia, and nose bleeds or other nasal discharges. She also denies dental diseases, hoarseness, and throat pain. Patient also denies ear pain, hearing loss, ringing in the ears, and discharge. She also denies blurring and any kind of visual changes. She also states that she does not experience chest pains, palpitations, PND, orthopnea, and edema. She also denies cough, wheezing, hemoptysis, and edema. The patient also reports no abdominal pain, diarrhea, constipation, and black tarry stools. She also states that she has observed no lumps, bumps or changes in her breasts. Patient also denies urinary incontinence, burning, and color changes in urine. She also denies using contraceptives and any STIs. She states that her last pap smear test was conducted in 2014. Patient denies experiencing back pain, swollen joints, stiffness and pain. She also denies syncope, seizures, transient paralysis, weakness, paresthesias, and episodes of black-outs. The patient also reports absence of swollen glands, increased thirst, increased hunger, and cold/heat intolerance. She also reports that she does not experience depression, anxiety, sleeping difficulties, and suicidal attempts/ideation.
Differential diagnoses for Ms. Smith includes false positive pregnancy, molar pregnancy and ectopic pregnancy. Additional testing showed positive urine HCG results. She also tested negative for UTI after urine analysis and observation of fetal heart tone (FHT) showed 156 BPM.
The signs and symptoms showed by the patient confirm pregnancy. The presence of HCG in the urine as showed by the home pregnancy test taken by the patient and the urine HCG test taken during the patient’s visit confirms pregnancy (Butler, Khanlian, and Cole, 2001). The presence of HCG protein in the patient’s urine signals fetal development and therefore pregnancy (Butler et al., 2001). But aside from the presence of HCG, the darkening of the cervix, menstrual misses, nausea, and decreased energy levels also signal pregnancy (Shields, 2014). Considering the presence of these signs and symptoms in the patient, she may be considered pregnant. However, considering the patient’s history of ectopic pregnancy, her signs and symptoms must be investigated more thoroughly to rule out ectopic pregnancy. HCG levels can still rise despite ectopic pregnancy so in order to detect it or rule it in, transvaginal ultrasonography (TVS) must be performed to the patient to see if the uterus is empty or bearing a fetus (Kirk, Bottomley, and Bourne, 2014; Shields, 2014). The patient must also be monitored to prevent hypertensive pregnancy which may increase pregnancy-related morbidity or mortality (Magee et al., 2014).
Patient must continue taking prenatal vitamins daily. Influenza vaccine must be administered. TdaP must also be administered at the 20th week of gestation. CBC, syphilis, HIV, and Hepatitis B screening will be performed at the patient’s next visit. Ultrasound must be completed today to confirm pregnancy and to get an estimated date of delivery. Rubella titer will be drawn to monitor patient’s immunity. Blood type and Rh factor will also be drawn to determine the presence of Rh incompatibility.
Patient’s tentative due date is on July 31, 2016. The patient must gain approximately 20-25 pounds based on her BMI. Given her history, the patient is a high-risk patient and must visit every 2 weeks until the 36th week of gestation and must come weekly after that until delivery. Patient must contact healthcare provider in episodes of bleeding, fever, contractions, severe or sudden swelling in the legs or ankles. The patient will be educated regarding diet and increasing iron intake. She must also be instructed to limit fish intake to one to two times a week to avoid mercury poisoning. Patient should not smoke or be exposed to secondhand smoking. She must also avoid drinking any types of alcohol and must not use any types of recreational drugs. Patient ill receive educational pamphlets which she may take home to review with her husband.
Butler, S.A., Khanlian, S.A., and Cole, L.A. (2001). Detection of Early Pregnancy Forms of Human Chorionic Gonadotropin By Home Pregnancy Test Devices. Clinical Chemistry, 47(12), 2131-2136. Retrieved from http://clinchem.org/content/47/12/2131.full
Kirk, E., Bottomley, C., and Bourne, T. (2014). Diagnosing ectopic pregnancy and current concepts in the management of pregnancy of unknown location. Human Reproduction Update, 20(2), 250-261. DOI: 10.1093/humupd/dmt047
Magee, L.A., Pels, A., Helewa, M., Rey, E., von Dadelszen, P., and Canadian Hypertensive Disorders of Pregnancy Working Group. (2014). Diagnosis, evaluation, and management of hypertensive disorders of pregnancy. Pregnancy Hypertension, 4, 105-145. DOI: 10.1016/j.preghy.2014.01.003
Shields, A.D. (2014). Pregnancy Diagnosis. Medscape. Retrieved from http://emedicine.medscape.com/article/262591-overview#a1