Family Medicine 12: 16-year-old female with vaginal
\nbleeding and UCG<\/p>\n
Date: April 25, 2020 10:01AM
\nLearning Objectives
\nThe student should be able to:
\nDescribe the essential features of a preconception consultation, including how to incorporate this content into any visit.
\nDiscuss chlamydia screening.
\nDemonstrate the use of the HEEADSS adolescent-interviewing technique.
\nRecognize pregnancy: intrauterine, ectopic (sample nursing essay examples by the best nursing assignment writing service), and miscarriage.
\nDiscuss options during an unplanned pregnancy.
\nSelect initial prenatal labs.
\nCounsel a pregnant patient for healthy behavior, folic acid supplementation, and immunizations.
\nOutline normal progression of symptoms and physical exam findings during pregnancy.
\nDemonstrate the management of a miscarriage, including the medical and social follow-up.
\nKnowledge
\nChlamydia: Epidemiology, Course of Disease, & Screening Recommendations
\nEpidemiology
\nChlamydial infection is the most common sexually transmitted bacterial infection in the United States. In 2007, more than 1.1
\nmillion chlamydia cases were reported to the CDC. It is thought that another million cases of chlamydia remain unreported.
\nCourse of disease
\nChlamydia is often insidious and asymptomatic. In women, genital chlamydial infection may result in urethritis, cervicitis, pelvic
\ninflammatory disease (PID), infertility, ectopic (sample nursing essay examples by the best nursing assignment writing service) pregnancy, and chronic pelvic pain. Chlamydial infection during pregnancy is related
\nto adverse pregnancy outcomes including miscarriage, premature rupture of membranes, preterm labor, low birth weight, and
\ninfant mortality.
\nScreening recommendations
\nThe USPSTF found fair evidence that nucleic acid amplification tests (NAATs) can identify chlamydial infection in asymptomatic
\nmen and women, including asymptomatic pregnant women, with high test specificity. In low prevalence populations, however, a
\npositive test is more likely to be a false positive than a true positive, even with the most accurate tests available.
\nQualities of a Good Screening Test
\n1. The condition should be an important health problem and the condition screened for must have a high prevalence in the
\npopulation.
\n2. There should be a latent stage of the disease.
\n3. There should also be effective treatment for the condition being screened.
\n4. Facilities for diagnosis and treatment should be available.
\n5. There should be a test or examination for the condition.
\n6. The test should be acceptable to the population and the total cost of finding a case should be economically balanced in
\nrelation to medical expenditure as a whole. The potential benefits of early detection and treatment of a condition need to be
\nweighed against many factors including: adverse side effects of the screening test, time and effort required (of both the
\npatient and the healthcare system) to take the test, financial cost of the test, potential psychological and physical harm of
\nfalse positive results (such as labeling and overtreatment), adverse effects of the treatment.
\n7. The natural history of the disease should be adequately understood.
\n8. There should be an agreed policy on who to treat.
\n9. Case-finding should be a continuous process, not just a “once and for all” project ( help with nursing paper writing from experts with MSN & DNP degrees).
\n10. An effective screening test should have very good sensitivity (identify most or all potential cases) and specificity (label
\nincorrectly as few as possible as potential cases). Even a test with a sensitivity of 95% will lead to many false positives when
\nthe prevalence of the condition is very low.
\nUnited States Preventive Services Task Force Recommendations for Chlamydia Screening
\nThe USPSTF
\n\u00a9 2020 Aquifer 1\/9
\nrecommends screening
\nfor chlamydia infection
\nin the following:
\nGrade
\nRecommendation
\nRationale:
\nAll sexually active
\nwomen age 24 and
\nyounger
\nSexually active
\nwomen age 25 and
\nolder who are at
\nincreased risk
\nGrade B
\nrecommendation
\nThere is direct evidence that screening reduces complications of chlamydial
\ninfection in women who are at increased risk, with a moderate magnitude of
\nbenefit. Such complications include pelvic inflammatory disease, infertility, and
\npremature delivery (among pregnant women).
\nThe USPSTF advises against screening women age 25 and older if not at increased risk, regardless of pregnancy status.
\nOnly the above categories are found to have a high enough pretest probability to recommend screening. Women (pregnant
\nor non-pregnant) in general are not recommended for chlamydial screening as the overall benefit of screening would be
\nsmall, given the low prevalence of infection among women not at increased risk.
\nRisk factors for chlamydial infection include a history of chlamydial or other sexually transmitted infection, new or multiple
\nsexual partners, inconsistent condom use, and exchanging sex for money or drugs. Risk factors for pregnant women are the
\nsame as for nonpregnant women.
\nFinally, the USPSTF states that there is “Insufficient” evidence for or against screening men.
\nThere are several good sources for preventive screening recommendations. The Guidelines for Adolescent Preventive Services
\n(GAPS) was developed by the AMA in 1993. Other recommendations include those from the American Academy of Pediatrics’
\nBright Futures and the U.S. Preventive Services Task Force.
\nAdolescent Health Counseling and Screening – Preventing Sexually Transmitted Infection and
\nUnintended Pregnancy
\nCounsel all sexually active adolescents regarding contraception.
\nOptions include: oral contraceptives, medroxyprogesterone (Depo-Provera) injections, transdermal options, IUDs, and the
\nvaginal ring (NuvaRing)
\nRemind patients these options do not protect against sexually transmitted infections
\nDiscuss condoms and abstinence
\nRecommend folic acid supplementation to prevent neural tube defects in the event of pregnancy
\nPreconception Counseling
\nFinding the opportunity to do preconception counseling in situations where the woman does not take the initiative to schedule a
\npreconception visit can be difficult. Whether it is walk-in \/ urgent care visits, sports pre-participation examinations, or adolescent
\nwell-child exams, the following list should be “on your radar screen” to effectively avail yourself of often scarce opportunities to
\nadvise women in these preconception issues.
\nPreconception Health Care Checklist:
\nGenetic
\nFolic acid supplement (400 mcg routine):
\nThe USPSTF recommends that all women “planning or capable of pregnancy” take a daily supplement containing 400 – 800
\nmcg of folic acid.
\nThe dose is increased for the following high-risk scenarios:
\nA. 1 mg in patients with diabetes or epilepsy
\nB. 4 mg in patients who bore a child with a previous neural tube defect
\nCarrier screening (ethnic background):
\nsickle cell anemia
\nthalassemia
\nTay-Sachs disease
\nCarrier screening (family history):
\ncystic fibrosis
\nnonsyndromic hearing loss (connexin-26)
\nScreen for infectious diseases, treat, immunize, counsel
\nHIV
\nSyphilis
\nHepatitis B immunization
\nPreconception immunizations (rubella, varicella)
\nToxoplasmosis-avoid cat litter, garden soil, raw meat
\nCytomegalovirus, parvovirus B19 (fifth disease)-frequent hand washing, universal precautions for child care and health care
\nEnvironmental toxins
\n\u00a9 2020 Aquifer 2\/9
\nOccupational exposures: Material Safety Data Sheets from employer
\nHousehold chemicals: avoid paint thinners and strippers, other solvents, pesticides
\nSmoking cessation: bupropion (Zyban), nicotine patches (Nicoderm)
\nScreen for alcoholism and use of illegal drugs
\nMedical assessment
\nDiabetes: optimize control, folic acid, 1 mg per day, off ACE-inhibitors
\nHypertension: avoid ACE inhibitors, angiotensin II receptor antagonists, thiazide diuretics
\nEpilepsy: optimize control; folic acid, 1 mg per day
\nDVT: switch from warfarin (Coumadin) to heparin
\nDepression\/anxiety: avoid benzodiazepines
\nLifestyle
\nRecommend regular moderate exercise
\nAvoid hyperthermia (hot tubs, overheating)
\nCaution against obesity and being underweight
\nScreen for domestic violence
\nAssess risk of nutritional deficiencies (vegan, pica, milk intolerance, calcium or iron deficiency)
\nAvoid overuse of Vitamin A (recommendations are to 750 mcg (2500 IU per day) with daily upper intake limit of 3,000 mcg
\n(10,000 IU))
\nAvoid overuse of Vitamin D (recommendations are 600 IU per day, tolerable upper intake is 4000 IU)
\nCaffeine (limit to the equivalent of two cups of coffee or six glasses of soda per day)
\nNote: The sugar intake in six glasses of soda is not recommended.
\nSigns and Symptoms of Pregnancy
\nAmenorrhea with fatigue, nausea, and\/or vomiting as well as breast changes, including tenderness, are the classic
\npresentations of pregnancy.
\nUrinary frequency can also occur. Although urinary frequency can be a normal symptom of pregnancy, the possibility of a UTI in
\na pregnant woman should also be considered.
\nSoftening of the cervix is known as Goodell’s sign, while softening of the uterus is known as Hegar’s sign.
\nThe bluish-purple hue in the cervix and vaginal walls is known as Chadwick’s sign and is caused by hyperemia.
\nEnlargement of the uterus can be detected by an experienced examiner as early as 8 weeks on bimanual exam. Around 12
\nweeks, the uterine fundus can be palpated above the symphysis pubis. Between 20 to 36 weeks of gestation, the uterine
\nenlargement, measured in centimeters, approximates gestational age and will become a routinely elicited physical exam finding.
\nFetal heart tones are typically elicited by hand-held Doppler between 10-12 weeks gestation.
\nFetal movement or “quickening” is detected by the mother around 18-20 weeks of gestation.
\nUnfortunately, the menstrual history is not an entirely reliable indicator of pregnancy. Only 68% of pregnant adolescents report
\nhaving missed a menses. Conversely, not every adolescent who misses a menses is pregnant because anovulatory cycles are
\nnormal in the early postmenarcheal years. Bleeding can occur in early pregnancy around the time of the missed menses as a
\nresult of an invasion of the trophoblast into the decidua (implantation bleed). Some adolescents mistake this bleeding for a
\nmenses, leading to a delay in diagnosis of pregnancy and potential misdating of the pregnancy. We should also remember that
\nyoung women who have not yet menstruated, but are sexually active, may be at risk for pregnancy because ovulation can
\noccasionally occur before the first menstrual period.
\nReproductive Choice Counseling
\nContinue the pregnancy…
\n…and raise the child.
\n…and create an adoption plan.
\nTerminate the pregnancy…
\n…medically
\n…surgically
\nAbortion restrictions in the U.S. vary state to state, as shown here:
\nhttps:\/\/www.guttmacher.org\/state-policy\/explore\/overview-abortion-laws
\nCalculating Estimated Gestational Age
\nCalculating the Estimated Gestational Age (EGA) based on the Last Normal Menstrual Period (LNMP). Calculating the EGA in this
\nmanner is not only convenient but ubiquitous in clinical practice. Keep in mind, however, that the actual embryonic age (e.g., the
\nage of the fetus since the date of conception) will typically be approximately two weeks less than the clinically calculated EGA
\nbased upon the LNMP.
\nThe other calculation used in clinical practice – which patients care a great deal about – is the Estimated Due Date.
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\nCalculating the estimated due date (EDD – sometimes referred to as the estimated date of confinement or EDC) from the last
\nmenstrual period is a relatively simple process that can be done with an obstetric “wheel”, with an electronic calculator (e.g.,
\nhttp:\/\/www.mdcalc.com\/pregnancy-due-dates-calculator ) or using Naegele’s Rule.
\nNaegele’s Rule is commonly described as starting with the first day of the last normal menstrual period, then:
\nadd 1 year
\nsubtract 3 months
\nadd 1 week
\nFor example, if a patient’s LNMP was 7\/10\/2009, then:
\n7\/10\/2010 (+1 yr)
\n4\/10\/2010 (-3 mo)
\n4\/17\/2010 (+1 wk)
\nThus, the EDD is 4\/17\/2010.
\nThere are a variety of error corrections to Naegele’s Rule and other ways to calculate the EDD in the first trimester that will be
\ndiscussed later.
\nHemodynamic Instability
\nTypically, a significant bleed will first cause the pulse to rise and then the blood pressure to drop. Despite the fact that blood
\npressure is normal, bleeding can continue for a while before the blood pressure reflects this. This finding really changes how
\nurgently you need to begin to make your assessment and, in some cases, intervene.
\nRhesus immune globulin (RhoGam)
\nRho(D) Immune Globulin is a critical part of modern obstetrics. Prior to the clinical use of this medication, Rh-negative mothers
\nwith Rh-positive first gestations were at high risk of having subsequent gestations and developing hemolytic anemia, hydrops,
\nand\/or fetal death. With every pregnancy, there is some passage of fetal red blood cells into the maternal circulation. This occurs
\nat either miscarriage or delivery and can even occur in small but significant quantities across the otherwise placental barrier.
\nWhen a mother with an intact immune system detects enough of the fetal Rho-D antigen, she forms antibodies to this antigen.
\nThis immune response is usually not robust enough to impact the first gestation, but subsequent gestations are at significant risk
\nof an immune response. When this occurs, the maternal antibodies attack the fetus’ red blood cells, causing hemolytic anemia,
\nwhich can lead to fetal hydrops and even fetal death.
\nRho(D) Immune Globulin administered at appropriate times interrupts the maternal immunologic process. You can visualize this
\nprocess by imagining the RhoGAM attaching to all of the fetal Rho-D antigenic load, making it immunologically “invisible” to the
\nmaternal immune system.
\nFirst Trimester Vaginal Bleeding
\nOne in four pregnant patients experience vaginal bleeding during the first trimester.
\nWhen women have significant bleeding in the first trimester, there is a 25-50% chance of miscarriage.
\nEctropion
\nEctropion: When the central part of the cervix appears red from the mucous-producing endocervical epithelium protruding
\nthrough the cervical os, onto the face of the cervix. It has no clinical significance and is common in women who are taking oral
\ncontraceptive pills.
\nEstimating Gestational Age Based on Last Known Menstrual Period and Ultrasound
\nRecall that Naegele’s rule for estimating date of delivery (EDD) is to subtract 3 months and add 7 days to the first day of the last
\nmenstrual period. Calculating today’s estimated gestational age is typically done with an obstetrical “wheel” or a handheld
\ncomputer, but can be counted from the EDD on any calendar.
\nUltrasounds have their own extensive nomograms that estimate gestational age from measured fetal size.
\nTrimester Measure
\nAccuracy
\nand
\nprecision
\nInterpretation
\nFirst
\ntrimester
\ncrown-rump length +\/- 1
\nweek
\nIf the EGA & EDD from the ultrasound measurements are within one week of the EGA \/
\nEDD estimated from the LNMP, today’s gestational age and the due date (EGA & EDD)
\nshould not change to reflect the ultrasound calculations, as in this case.
\nIf, however, the ultrasound measurements suggest an EGA & EDD that is greater than
\nseven days from the EGA & EDD calculated from the LNMP (or, in some cases, if the
\nLNMP is historically inaccurate), then the estimated gestational age today, as well as
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\nthe estimated due date, should be changed to reflect the ultrasound measurements
\nand estimates.
\nSecond
\ntrimester
\n1. biparietal
\ndiameter
\n2. head
\ncircumference
\n3. abdominal
\ncircumference
\n4. femur length
\n+\/- 2
\nweeks
\nSame.
\nThird
\ntrimester
\n+\/- 3
\nweeks
\nFetal size cannot be used accurately to assess EGA or EDD and should not change a
\ndue date.
\nThis is because of the response of the fetus to internal and external insults. During the
\n1st and 2nd trimester, many problems that develop result in pregnancy loss and\/or
\nteratogenensis. However, during the third trimester, many of fetal and maternal
\nchallenges manifest themselves in fetal growth. Two examples would be macrosomia
\ndue to gestational diabetes or intrauterine growth restriction as a part of the preeclampsia syndrome. Additionally, fetal size discrepancies can be either familial or
\nidiopathic.
\nSince the ultrasound estimate of gestational age and due date is based on
\nmeasurements of fetal size compared to a computerized nomogram, these thirdtrimester measurements should not be used for dating the EGA or EDD.
\nSpontaneous Abortion: Incidence, Causes, and Recurrence
\nIncidence
\nMiscarriages are very common: about one-third of all pregnancies end in miscarriage.
\nCauses
\nWomen who have a spontaneous abortion and their partners frequently struggle with guilt about their role in the loss. Physicians
\nshould address the issue of guilt with their patients and allay any concerns that they may have “caused” the spontaneous
\nabortion. There is no proof that stress or physical \/ sexual activity causes miscarriage. About half of all miscarriages that occur in
\nthe first trimester are caused by chromosomal abnormalities.
\nRecurrence
\nMost women (87 percent) who have miscarriages have subsequent normal pregnancies and births.
\nClinical Skills
\nHEEADSSS Adolescent Interview
\nPre-participation exams are a great opportunity for prevention and counseling, as otherwise healthy adolescents may not come in
\nfor this routinely.
\nHEEADSSS covers the following issues:
\nHome
\nEducation \/ Employment
\nEating
\nActivities
\nDrugs
\nSexuality
\nSuicide \/ Depression
\nSafety \/ Violence
\nRemember that in caring for adolescents, every effort should be made to encourage the patient to involve parents in their
\nhealthcare decisions. Nevertheless, teens have a right to be interviewed and examined without a parent or guardian in the room.
\nManagement
\nManagement of Inevitable Abortion
\nIn the setting of an inevitable (or similarly, an incomplete) spontaneous abortion, the traditional choices for management are
\n\u00a9 2020 Aquifer 5\/9
\nexpectant management or surgical management.
\nExpectant management means watchful waiting with precautions regarding unusual amounts of bleeding or pain, or fever, and
\nis effective in over 75% of cases in this setting. The disadvantage with this course of action is that it can take up to a month for
\nthe products of conception to be completely expelled. This timeframe might not normally be a problem, but a spontaneous
\nabortion is usually complicated by sadness, grief, and even guilt. Expectant management can delay emotional closure.
\nNevertheless, this is a viable course of action.
\nSurgical options include dilitation and curettage (D&C), with or without vacuum aspiration, or manual or electric vacuum
\naspiration. These choices depend on a variety of factors, including primarily local resources and the surgeon’s preference and
\nexperience. The main indication for suction D&C is unusually heavy bleeding and patient preference. The main contraindication is
\nactive pelvic infection and patient refusal.
\nMedical management, despite being off-label, is a useful third option that is becoming more common. The most common
\nprotocol involves the vaginal administration of 800 mcg of misoprostol (Cytotec), possibly repeated on day three. Success with this
\nmethod is generally around 95%, and the time to completion is generally 3-4 days (but may take up to 2 weeks), as opposed to 2-
\n6 weeks with expectant management.
\nFinally, confirming the receipt of rhesus immune globulin (RhoGam) in the Rhesus negative patient is advisable. If it was not given
\npreviously, it should now be administered.
\nStudies
\nInitial Pregnancy Laboratory Studies
\nCBC is important to detect various nutritional and congenital anemias, and to detect platelet disorders.
\nRubella immunity should be tested by assessing the presence of IgG antibodies. If the patient isn’t immune, they should
\nreceive a postpartum immunization. The Rubella and the MMR vaccine is a live-virus vaccine and should not be used during
\npregnancy. (Note: This is part of the initial prenatal laboratory workup, despite the childhood immunization history.)
\nHepatitis B surface antigen tests for Hepatitis B, which is a major risk to the newborn. (Note: This is part of the initial
\nprenatal laboratory workup, despite the childhood immunization history.)
\nBlood type to detect rhesus antibody presence. RH(D)-negative women should receive anti (D)-immune globulin to prevent
\nhemolytic disease of the newborn.
\nRPR tests for syphilis , which is of particular concern during pregnancy because of the risk of transplacental infection of
\nthe fetus. Congenital infection is associated with several adverse outcomes, including:perinatal death, premature delivery,
\nlow birth weight, congenital anomalies, and active congenital syphilis in the neonate.
\nHIV status should be checked as the risk of perinatal transmission can be reduced from 15-40% without treatment to less
\nthan 2% with antiretroviral therapy and avoidance of breastfeeding and labor.
\nIt is probably not necessary to test serum hCG as well as urine hCG to confirm pregnancy, in the setting of a positive urine
\nhCG.
\nHowever, as early pregnancy urine hCG concentrations are lower than serum hCG concentrations, it is possible to have a positive
\nserum hCG result, even with a negative urine hCG result.
\nAdditionally, one must specify a qualitative (positive vs. negative) vs. a quantitative serum hCG. Quantitative serum hCG levels
\nrise at a predictable rate, so serial testing of serum hCG levels can be useful to determine viability or to diagnose an ectopic (sample nursing essay examples by the best nursing assignment writing service)
\npregnancy, although one measurement alone is not sufficient to accurately estimate gestational age.
\nAn ultrasound would not be the best test to order at an early stage of pregnancy. For example, at five weeks estimated
\ngestation, an embryo would typically not be seen. Furthermore, the results would be difficult to interpret without a serum
\nquantitative beta human chorionic gonadotropin test (quantitative pregnancy test).
\nRecommended Laboratory Studies to Investigate First Trimester Vaginal Bleeding
\nCBC: The main utility of the CBC is for the Hemoglobin \/ Hematocrit. The white blood cell (WBC) count is limited in its
\nusefulness to detect infection (and thus a septic abortion) during pregnancy because most pregnant patients have a mild
\nleukocytosis. Nevertheless, if significantly elevated, or associated with a bandemia, this test would need to be factored into
\nthe consideration of a septic abortion. Wet mount preparation for trichomonas, as well as PCR testing for gonorrhea and chlamydia: All sexually
\ntransmitted infections can cause vaginal bleeding. These tests should be obtained in this clinical context, despite a
\npreviously normal recent result.
\nProgesterone: Laboratory testing for progesterone is most useful in extreme situations. If the result is >25, it is highly
\nassociated with a sustainable intrauterine pregnancy. If the result is <5, it is highly associated with an evolving miscarriage
\nor ectopic (sample nursing essay examples by the best nursing assignment writing service) pregnancy. Levels between 5 and 25 have minimal diagnostic value in distinguishing intrauterine from ectopic (sample nursing essay examples by the best nursing assignment writing service)
\npregnancy. Algorithms for the diagnosis of ectopic (sample nursing essay examples by the best nursing assignment writing service) pregnancy emphasizing progesterone measurements have been
\nassociated with a higher use of surgical management and often miss ectopic (sample nursing essay examples by the best nursing assignment writing service) pregnancy since 85% of ectopic (sample nursing essay examples by the best nursing assignment writing service) pregnancies
\nwill have a normal progesterone level. Nevertheless, the test remains valuable because of its positive and negative
\npredictive value at the extremes of the reference range. In many labs, it is a common and quick test, which makes it
\nfrequently ordered.
\nQuantitative beta-human chorionic gonadotropin (quant. beta-hcg): This test has enormous significance, and when
\ncombined with the pelvic ultrasound, they are the definitive diagnostic modalities. However, in isolation, one beta-hCG can
\nbe challenging to interpret, especially without the ultrasound results. Human chorionic gonadotropin is secreted by the
\ntrophoblastic cells very early in embryonic life (day 7, post-ovulation). Additionally, testing for the beta-subunit is exquisitely
\nsensitive (down to 5 mIU\/mL) and specific (the placenta is the only normal tissue that excretes beta-hCG). By the expected
\ndate of menses, the beta-hCG is usually > or = 100 mIU\/mL.
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\nFurthermore, in a normal pregnancy, the beta-hCG approximately doubles every 48 hours for the first 6-7 weeks of gestation.
\nHowever, an intrauterine pregnancy may not be conclusively detected until the quantitative beta-hCG reaches 1500-1800. To
\ndetect an intrauterine pregnancy by transabdominal ultrasound, the beta-hCG will typically be >5000 mIU\/mL. In both ectopic (sample nursing essay examples by the best nursing assignment writing service)
\ngestations and spontaneous abortions, hCG levels are usually lower than normal and increase at less-than-normal rates during
\nearly gestation. Molar pregnancy and multiple gestations are both associated with higher-than-normal hCG levels.
\nNot recommended:
\nType and screen: Knowing the Rhesus status is critical, as all Rh negative women who are pregnant need to be given RhoGam
\nduring any episode of bleeding. However, this does not need to be repeated after initial type and screen, especially in a setting
\nthat does not appear that this is a major bleed. If the bleeding is of great volume, a type and screen would be warranted both for
\npotential transfusion and for Kleihauer-Betke testing, which helps to estimate the quantitative amount of fetal hemoglobin in the
\nmaternal circulation and with dosing RhoGam.
\nSpontaneous Abortion
\nSpontaneous abortion is the loss of a pregnancy without outside intervention before 20 weeks’ gestation. Spontaneous abortions
\ncan be subdivided into:
\nThreatened abortion – bleeding before 20 weeks gestation.
\nThreatened abortion is simply a pregnancy complicated by bleeding before 20 weeks gestation, and is – in some ways – a “catchall” descriptive diagnosis.
\nInevitable abortion – dilated cervical os.
\nIncomplete abortion – some but not all of the intrauterine contents (or products of conception) have been expelled.
\nMissed abortion – fetal demise without cervical dilitation and\/or uterine activity (often found incidentally on ultrasound
\nwithout a presentation of bleeding).
\nSeptic abortion – with intrauterine infection (abdominal tenderness and fever usually present).
\nComplete abortion – the products of conception have been completely expelled from the uterus.
\nClinical Reasoning
\nDifferential of First Trimester Vaginal Bleeding
\nMost Likely Diagnoses
\nThere are many important causes of bleeding in early pregnancy, but the three most common are spontaneous abortion,
\nectopic (sample nursing essay examples by the best nursing assignment writing service) pregnancy, and idiopathic bleeding in a viable pregnancy.
\nFinding Significance
\nPhysical
\nExam
\nFindings
\nA cervical os dilated with obvious bleeding lends support to the diagnosis of a spontaneous abortion.
\nA distended, acute abdomen may turn one’s attention to the immediate possibility of a ruptured ectopic (sample nursing essay examples by the best nursing assignment writing service)
\npregnancy.
\nHowever, an unremarkable pelvic exam does not rule out either a spontaneous abortion, ectopic (sample nursing essay examples by the best nursing assignment writing service) pregnancy,
\nor a normal pregnancy.
\nQuantitative
\nbeta-hCG
\nNeither transabdominal nor transvaginal ultrasound can reliably detect an intrauterine pregnancy at a betahCG level less than 1500 mIU\/mL. A quantitative beta-hCG slightly less than 1500 mIU\/ml does not argue for
\nor against a spontaneous abortion, an ectopic (sample nursing essay examples by the best nursing assignment writing service) pregnancy, or a normal pregnancy.
\nHowever, the quantitative beta-hCG should approximately double every 48 hours in a normal pregnancy, so
\nthe velocity of the increase or decrease is a more useful diagnostic modality than the point value in a stable
\npatient. If the patient is stable, 1-2 serial hCG measurement(s) can prove diagnostically useful and often
\nconclusive when combined with a repeat ultrasound.
\nUltrasound
\nAn ovarian cyst is not necessarily abnormal, and a report stating “cannot rule out ectopic (sample nursing essay examples by the best nursing assignment writing service) pregnancy” is a
\nclassic reminder by the radiologist that they simply cannot rule out ectopic (sample nursing essay examples by the best nursing assignment writing service) pregnancy.
\nOne should be neither cavalier that such an ultrasound finding is a benign finding nor overly aggressive in
\n“treating” for a suspected ectopic (sample nursing essay examples by the best nursing assignment writing service) pregnancy in a stable patient. Better to make the diagnosis more certain. It
\nwould be a mistake to assume a confirmed ectopic (sample nursing essay examples by the best nursing assignment writing service) pregnancy and to begin either medical or surgical
\ntreatment for ectopic (sample nursing essay examples by the best nursing assignment writing service) pregnancy. This may, after all, prove in 48 hours to be the corpus luteum cyst
\nsupporting a normal intrauterine pregnancy.
\nIntrauterine contents (e.g., gestational sac, fetal pole, etc.) are not expected to be seen until the quantitative
\nbeta-hCG reaches > 1500 IU\/L, so a serial reading (in the stable patient) is needed. In a stable patient
\nwithout active bleeding, serial readings every 48-72 hours would be appropriate.
\nAt each lab reassessment, a clinical assessment should be done as well. At any time, a spontaneous abortion can cause
\nhemodynamic instability or a ruptured ectopic (sample nursing essay examples by the best nursing assignment writing service) can prove life threatening.
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\nIf the patient was or has become unstable, a dilatation and curettage (for an unstable spontaneous abortion) or a diagnostic
\nlaparoscopy or laparotomy (for a suspected ruptured ectopic (sample nursing essay examples by the best nursing assignment writing service)) would be the most appropriate course of action.
\nLess Likely Diagnoses
\nGestational trophoblastic disease (GTD), or molar pregnancy, is a hetergeneous constellation of conditions whereby the placenta
\nacts like a tumor. GTDs are usually benign, but can sometimes be malignant. Typically, they have a characteristic appearance on
\nultrasound and are associated with markedly increased (>100,000 mIU\/mL) quantitative hCG levels.
\nVaginal trauma and cervical pathology are unlikely if nothing abnormal is seen on physical exam. However, these can’t be ruled
\nout conclusively until gonorrhea and chlamydia results are obtained.
\nReferences
\nAbortion rules by state: http:\/\/www.guttmacher.org\/statecenter\/index.html
\nAmerican Academy of Family Physicians. AAFP Policy on Reproductive Decisions: 1989-2006.
\nhttp:\/\/www.aafp.org\/online\/en\/home\/policy\/policies\/r\/reproductdecisions.html. Accessed April 28, 2017.
\nBrudage SC. Preconception Health Care. Am Fam Physician. 2002 Jun 15;65(12):2507-2515.
\nhttp:\/\/www.aafp.org\/afp\/2002\/0615\/p2507.html. Accessed April 28, 2017.
\nCenters for Disease Control and Prevention. Chickenpox Vaccination: What Everyone Should Know.
\nhttps:\/\/www.cdc.gov\/vaccines\/vpd\/varicella\/public\/index.html. Accessed April 17, 2017.
\nCenters for Disease Control and Prevention. Sexually transmitted diseases treatment guidelines 2006. MMWR Recomm Tep.
\n2006;55(RR-11):7.
\nCleveland Clinic. Miscarriage. http:\/\/my.clevelandclinic.org\/disorders\/Miscarriage\/hic_Miscarriage.aspx. Accessed April 28, 2017.
\nEdelman A, Anderson J, Lai S, Braner DAV, Tegtmeyer K. Pelvic examination, N Engl J Med. 2007; 356(26):e26.
\nhttp:\/\/content.nejm.org\/cgi\/content\/full\/356\/26\/e26. Accessed April 28, 2017.
\nEdelman A, Anderson J, Lai S, Braner DAV, Tegtmeyer K. Pelvic examination. N Engl J Med. 2007;356(26):e26 (Web only).
\nhttp:\/\/content.nejm.org\/cgi\/content\/full\/356\/26\/e26. Accessed April 28, 2017.
\nFact Sheet on Vitamin A: http:\/\/ods.od.nih.gov\/factsheets\/VitaminA-HealthProfessional\/
\nFact Sheet on Vitamin D: http:\/\/ods.od.nih.gov\/factsheets\/VitaminD-HealthProfessional\/
\nFossum GT, et al. Early detection of pregnancy with transvaginal ultrasound. Fertil Steril. 1998;49:788.
\nGabbe S, Niebyl J, Simpson J. Red Cell Alloimmunization. In: Obstetrics: Normal and Problem Pregnancies. 5th ed. Philadelphia:
\nChurchill Livingstone Elsevier; 2007.
\nGriebel C, Halvorsen J, Golemon, T, Day A. Management of Spontaneous Abortion. Am Fam Physician. 2005 Oct 1;72(7):1243-1250.
\nhttp:\/\/www.aafp.org\/afp\/2005\/1001\/p1243.html. Accessed April 28, 2017.
\nGriebel CP, Halvorsen J, Golemon TB, Day AA. Management of spontaneous abortion. Am Fam Physician. 2005;72:1243-50.
\nhttp:\/\/www.aafp.org\/afp\/2005\/1001\/p1243.html. Accessed April 28, 2017.
\nInstitute of Medicine, Food and Nutrition Board. Dietary Reference Intakes for Calcium and Vitamin D. Washington, DC: National
\nAcademy Press, 2010.
\nLozeau AM, Potter B. Diagnosis and management of ectopic (sample nursing essay examples by the best nursing assignment writing service) pregnancy. Am Fam Physician. 2005;72:1707-14.
\nhttp:\/\/www.aafp.org\/afp\/2005\/1101\/p1707.html. Accessed June 2, 2017.
\nMeyers, DS, Halvorson, H, Luckhaupt, S. Screening for chlamydial infection: an evidence update for the U.S. Preventive Services Task
\nForce. Ann Intern Med. 2007;147:135. http:\/\/www.ahrq.gov\/clinic\/uspstf\/uspschlm.htm. Accessed April 26, 2017.
\nNational Institute of Health Office of Dietary Supplements
\nNew York Times. (Slideshow) Rh Incompatibility. NYTimes Health Section: http:\/\/ow.ly\/JqnW. Accessed April 28, 2017.
\nPolaneczky M, O’Connor K. Pregnancy in the adolescent patient: Screening, diagnosis, and initial management. Pediatr Clin North Am.
\nAugust, 1999;46(4):649-70, x.PMID:10494250.
\nSperoff L, et al. Ectopic (sample nursing essay examples by the best nursing assignment writing service) Pregnancy. In Clinical Gynecologic Endocrinology and Infertility. Ed. 5. Baltimore, MD: Williams & Wilkins;
\n1994.
\nU.S. Preventive Services Task Force. Folic acid for the prevention of neural tube defects: U.S. Preventive Services Task Force
\nrecommendation statement. Ann Intern Med 2009;150:626-31.
\nhttp:\/\/www.uspreventiveservicestaskforce.org\/uspstf09\/folicacid\/folicacidrs.htm
\nUSPSTF. Folic Acid for the Prevention of Neural Tube Defects: U.S. Preventive Services Task Force Recommendation Statement. Ann
\nInt Med, 2009; 150:626-631. http:\/\/annals.org\/aim\/article\/744473\/folic-acid-prevention-neural-tube-defects-u-s-preventive-services.
\nAccessed March 6, 2017.
\nUSPSTF. Folic Acid to Prevent Neural Tube Defects. http:\/\/www.uspreventiveservicestaskforce.org\/uspstf\/uspsnrfol.htm
\nWilson JMG, Jungner G. (1968) Principles and practice of screening for disease (large pdf). WHO Chronicle Geneva:World Health
\nOrganization. 22(11):473. Public Health Papers, #34. https:\/\/www.ncbi.nlm.nih.gov\/books\/NBK138555\/ Accessed November 21, 2016.
\n\u00a9 2020 Aquifer 8\/9
\nSOAP NOTE
\nName: Patient\t01\/02\/1998\tTime: 11:00 am
\nAge: 18\tSex: Female
\nSUBJECTIVE
\nCC:
\n\u201cI need to fill out a Physical form for college\u201d.<\/p>\n
HPI:
\nPt is an 18 year old female presenting to the office today for a physical as a requirement for her college application. She presents for a well-visit. Her primary caregiver is her mother and father. Help and support is provided by both parents. There are no behavioral problems.
\nMedications:
\nNo current medications
\nPMH
\nAllergies: NKDA
\nMedication Intolerances:
\nNone
\nChronic Illnesses\/Major traumas
\nNone
\nChronic Health Problems:
\nNone
\nHospitalizations\/Surgeries
\nNone
\nOther:
\nImmunizations: Vaccinations up to date. PPD to be placed today. Meningitis B vaccine to be given today (#1)
\nEnvironmental hazards: Denies any environmental hazards. Able to perform ADLs without difficulty.
\nSafety measures: Wears seat belt and follows speed limits.
\nExercise and leisure: She is active and goes to the gym daily.
\nSleep: Sleeps 9 hours nightly.
\nDiet: Obesity prevention. No difficulties eating. Consumes 3meals\/day.
\nMenstruation: LNMP 7\/15\/2016
\nFamily History
\nMother-cluster headaches
\nSocial History
\nDenies drinking. Denies smoking. Denies illicit drugs.
\nROS
\nGeneral
\nDenies fatigue. Denies fever, night sweats or recent weight gain or loss. \tCardiovascular
\nDenies chest pain. No murmur, bruits, palpitations, or edema.
\nSkin
\nNo cyanosis or clubbing noted. Skin is warm, dry and intact. \tRespiratory
\nDenies cough. Denies hemoptysis, wheezing, or custom essay writing service exposure to TB. Denies SOB.
\nEyes
\nDenies complaints of blurred vision or visual disturbances reported.\tGastrointestinal
\nDenies abdominal pain, nausea, vomiting, dysphagia or abnormal stools.
\nEars
\nDenies hearing loss discharge or ear pain. \tGenitourinary\/Gynecological
\nDenies any frequency, hesitancy, nocturia or urgency.
\nNose\/Mouth\/Throat
\nDenies dryness, hoarseness, or mouth pain. \tMusculoskeletal
\nDenies pain.
\nBreast
\nDenies any lumps or bumps.\tNeurological
\nDenies syncope or headache, focal weakness, numbness, paresthesia\u2019s, tremors, gait instability, falls or memory loss.
\nHeme\/Lymph\/Endo: Denies easy bruising, bleeding, or blood clots. Denies increased hunger or thirst. Denies recent weight loss. Denise night sweats or swollen glands. \tPsychiatric
\nDenies any anxiety or suicidal ideations
\nOBJECTIVE
\nWeight 334 lbs BMI 55.58\tTemp 98.6\tBP 110\/70
\nHeight 65 in\tPulse 68\tResp 16
\nGeneral Appearance
\nThis is a pleasant 18 year old Caucasian young female that presents for a physical exam and forms to be completed for college and immunizations.
\nSkin
\nNo cyanosis or clubbing noted. Skin is warm, dry and intact.
\nHEENT
\nHead: Head is normocephalic, no tenderness during palpation.
\nEyes: PERRLA (3 mm)
\nEars: External auditory canals clear. Tympanic membranes intact, pearly gray with light reflex noted.
\nNose: Nasal mucosa moist without drainage, septum midline.
\nNeck: Supple. Full ROM. No lymphadenopathy; no occipital nodes. No thyromegaly or nodules or masses palpated. Oral mucosa pink and moist. Trachea midline.
\nCardiovascular
\nSinus rhythm, S1 and S2. No S3, S4, rubs, clicks or murmurs noted. No thrills, heaves or lifts with palpation. Capillary refill 2 seconds. Pulses 3+ throughout. No edema noted.
\nRespiratory
\nRespirations regular, even and unlabored. Chest expansion is symmetrical. No crackles auscultated. Lungs clear bilaterally and diminished to the bases. No tactile fremitus.
\nGastrointestinal
\nAbdomen soft. BS+ in all 4 quadrants. Abdomen soft, non-tender. No hepatosplenomegaly.
\nBreast
\nBreasts are free from masses or tenderness. No discharge, no dimpling, wrinkling or discoloration noted.
\nGenitourinary
\nNo bladder tenderness on palpation. Vaginal walls are pink and clear. LMNP 7\/15\/2016
\nMusculoskeletal
\nNo swelling, crepitus palpated. Full ROM.
\nNeurological
\nSpeech clear. Good tone. Posture erect with stable gait.
\nPsychiatric: Alert and oriented. Hygiene appropriate. Maintains eye contact. Speech is clear and audible. Answers questions appropriately.
\nLab Tests
\nNone
\nSpecial Tests
\nNone
\nDiagnosis<\/p>\n
Differential Diagnoses
\no\t1-Obesity in children
\no\t2-Diabetes
\no\t3-Binge eating
\nPresumptive Diagnosis
\no\tObesity in children (E66.9)
\nPlan\/Therapeutics
\no\tPlan:
\n\uf0a7\tDiagnosis: Obesity in children (E66.9)
\n\uf0a7\tFurther testing-none
\n\uf0a7\tMedication-none at this time
\n\uf0a7\tEducation (Cash & Glass, 2011): Lifestyle modifications, exercise, and physical activity:
\n\u2022\tEncouraged to participate in physical activity and limit time watching TV or playing video games. Encouraged a regular walking activity for 20-30 minutes per day to help with weight control.
\n\u2022\tDiscussed a diet in low fat and provided literature. Also encourage her to share information with her parents. She stated \u201cmy mom cooks allot of fried foods\u201d. I explained to her that if the family is involved in changing patterns, it can help with the weight loss goal (Ogden, Yanovski, & Carroll, 2007)
\n\u2022\tIdentify and monitor any cardiovascular complications.
\n\u2022\tEncouraged to get a food diary to identify triggers.
\n\uf0a7\tPharmaceutical therapy(Cash & Glass, 2014):
\n\u2022\tIf an adequate trial of exercise does not work (6 months) consider pharmaceutical therapy such as appetite suppressants.
\n\uf0a7\tFollow up (Cash & Glass): Follow up with patient in 1 month. If diet and exercise is not providing results consider a referral to a registered dietician.<\/p>\n
Assessment of patient encounter<\/p>\n
Reference
\nCash, J., & Glass, C. (2011). Family practice guidelines (2nd ed.). New York, NY: Springer Publishing Company, LLC.
\nOgden, CL., Yanovski, SZ., & Carroll KM. The epidemiology of obesity. Gastroenterology. May 2007. 132:2087-2102<\/p>\n","protected":false},"excerpt":{"rendered":"
Family Medicine 12: 16-year-old female with vaginal bleeding and UCG Date: April 25, 2020 10:01AM Learning Objectives The student should be able to: Describe the\u2026<\/p>\n","protected":false},"author":1,"featured_media":0,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[10601,10596,10882,479,537,172,478,10597,10599,10595],"tags":[10524,10522,10890,10561,10883,10889,10515,10521,10696,10518,10888,10887,10886,10885,10884,10525],"class_list":["post-125690","post","type-post","status-publish","format-standard","hentry","category-assignment-help-by-uks-no-1-writing-service","category-assignment-writers-canada-university-cost","category-free-ai-english-assignment-writers-china","category-nursing-course-hero","category-nursing-essay-pro","category-nursing-study-bay","category-nursing-study-pool","category-professional-assignment-writers-usa","category-uae-1-cheap-assignment-writing-service","category-write-a-word-essay","tag-apa-citation-format-assignment","tag-assignment-writers-australia-college-student","tag-best-nursing-case-study-writing-services","tag-buy-essay-usa","tag-case-study-nursing-writing-services-for-care-plans","tag-free-nursing-case-study-writing-services","tag-help-write-a-page-assignment","tag-i-need-someone-to-do-my-assignment-within-hours","tag-need-assistance-completing-the-assignment","tag-need-to-write-an-essay","tag-nursing-case-studies-with-answers","tag-nursing-case-study-paper-example","tag-nursing-case-study-template-examples-of-case-studies-nursing","tag-pharmacology-case-study","tag-soap-note-case-study","tag-write-pages"],"_links":{"self":[{"href":"https:\/\/www.studyproessays.com\/help\/wp-json\/wp\/v2\/posts\/125690","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/www.studyproessays.com\/help\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/www.studyproessays.com\/help\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/www.studyproessays.com\/help\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/www.studyproessays.com\/help\/wp-json\/wp\/v2\/comments?post=125690"}],"version-history":[{"count":0,"href":"https:\/\/www.studyproessays.com\/help\/wp-json\/wp\/v2\/posts\/125690\/revisions"}],"wp:attachment":[{"href":"https:\/\/www.studyproessays.com\/help\/wp-json\/wp\/v2\/media?parent=125690"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/www.studyproessays.com\/help\/wp-json\/wp\/v2\/categories?post=125690"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/www.studyproessays.com\/help\/wp-json\/wp\/v2\/tags?post=125690"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}