Student reply. Comment and give your feed back and support diagnosis with evidence ApA format. 2 replies due in 7 hours
Case Scenario 2
Subjective
CC: “ I have been experiencing urinary frequency and burning for the past 2 days”
HPI: Lisa is a 29-year-old female G3P2 at 28 weeks EGA who is coming to the clinic for her routine checkup. She is Rh negative. Her VS are normal and prenatal routine
screenings are WNL. Lisa asks if it is normal to be experiencing frequency and mild burning when she urinates which she says has increased over the last 2 days. She has been drinking more water recently and thinks that maybe this is causing the urinary frequency.
HPI Questions:
· What brings you today? – As per patient she is experiencing urinary frequency and mild dysuria that it’s been worsening for the past 2 days.
· Are you currently sexually active? – Patient states she is currently sexually active.
· Are you in a monogamous relationship? – Patient is in a monogamous relationship with her husband for 15 years.
· When did the symptoms started? – Patient states urinary frequency and burning started 2 days ago.
· Can you describe where do you feel the burning? – Patient states she feels the burning in the urethra when she urinates.
· Is it intermittent or constant? – She states the burning is intermittent, whenever she urinates, and the frequency is constant.
· Is there any associated symptoms with the burning? – As per patient she has urinary frequency along with the dysuria, but she denies hematuria, flank pain, suprapubic pain, fevers, nausea or vaginal discharge.
· Is there anything that makes it better? Is there anything that makes it worse? – Patient believes that her increasing intake of water is leading to increased urination.
· Did you have any complications with your previous pregnancies? – Patient denies any complications with her previous pregnancies.
· Do you use condoms for STI prevention? – Patient reports the use of condoms for STI prevention.
PMH:
· Medical Hx: Patient denies history of a previous STDs, kidney or cardiovascular disease, DM, anemia, uterine fibroids, endometriosis, breast or uterine cancer or any other type of cancers.
· Medications: Patient takes prenatal vitamins and folic acid.
· Allergies: Patient denies any allergies to medications or foods.
· Surgical: Patient denies any past surgeries.
· OB: Patient is G3P2. Natural vaginal birth without complications in previous pregnancies. Rhogam administration with previous pregnancies.
· Immunizations: HPV vaccination at 11 and 12 years old. Patient to receive Tdap vaccine received at 27 weeks of gestation.
· Family: Patient denies any family history.
· Childhood diseases: Patient denies any childhood diseases.
· Social: Patient denies smoking, drinking alcohol, illegal drug use or engaging in risky sexual behavior. Patient eats a balanced diet.
ROS
· General: patient denies fevers, chills, fatigue or malaise.
· Breasts: Patient reports slightly darkened areola. Patient denies lumps on breasts, discharge from nipple or changes in texture of the breast.
· HEENT: Patient denies any head trauma, vision changes, photophobia, ear pain or hearing loss, rhinorrhea, sore throat, lymphadenopathy, swollen neck or difficulty swallowing.
· Neuro: patient denies headaches, vision changes, paresthesia or dizziness.
· Cardio: patient denies palpitations, chest pain or peripheral edema.
· Respiratory: patient denies any new onset of shortness of breath or cough.
· Endo: Patient reports increased urinary frequency and increased water intake. Patient denies night sweats or heat/cold intolerance.
· GU: Patient reports increased urinary frequency and mild burning with urination for the past 2 days. Patient denies hematuria, flank pain, or incontinence.
· GI: patient denies change in bowel habits or incontinence.
· Musculoskeletal: patient denies any new issues with ambulation, pain or joint stiffness.
· Hem: patient denies easy bruising.
· Psych: patient denies suicidal ideations or depression.
Objective
Assessment:
VS: BP: 110/70, HR: 74, RR: 17, O2: 100 RA, Temp: 36.4, Pain: 0 out 10, Weight: 130 lbs, Height: 5’4, BMI: 22.3.
Physical Findings:
· General: Patient alert and oriented x 4, dressed appropriately, well-nourished, cooperative and answering questions correctly. Gained 3 pounds since last visit.
· Breasts: no rash, erythema or lumps noted, skin usual for ethnicity.
· HEENT: head normocephalic, hair throughout, no trauma noted. Pupils PERRLA, EOMI intact, non-icteric, no exudates. Tympanic membrane is visible and translucent, hearing intact, no erythema, trauma or exudate noted. Nares patent bilaterally, no rhinorrhea present, symmetric septum, no inflammation of nasal mucosa noted. Uvula midline, no exudates or pain. Patient able to swallow, neck is supple, no JVD, no masses or lymphadenopathy noted, thyroid WNL.
· Heart: S1, S2 present, no gallops or clicks noted upon auscultation, pulses present +2 bilaterally, no extremity edema noted.
· Lungs: symmetric expansion, no accessory muscle use, clear to auscultation.
· Neuro: awake, alert, and oriented, speech is clear, cranial nerves intact 1-12, DTR intact with symmetric response. No nystagmus noted.
· GI: pregnant state, normal for 28 weeks, fundal height of 28 cm, abdomen soft, non-tender, non-guarded and no CVA tenderness.
· GU: external genitalia is without any lesions, swelling, erythema or irritation. No discharge noted upon examination. Speculum examination deferred at this time.
· Musculoskeletal: Steady gait, no tremors, weakness or swelling noted. ROM intact at time of examination.
Presumptive Diagnosis:
· 0: Dysuria
· 8: Polyuria
· 0: Frequency of micturition
· 0: Urinary tract infection, site not specified.
· 13: UTI in the third trimester: Due to a shorter urethra and its closeness to the perineum, women have a greater UTI rate than men. The urethra carries bacteria from the colonized perineum to the bladder and kidneys. Pregnancy-related urinary tract alterations increase UTI risk. In the symptomatic woman, a UTI (or acute cystitis) is diagnosed when any amount of a single organism is detected. (Jordan et al., 2019. P 234).
· Pertinent positive: dysuria, urinary frequency
· Pertinent negative: hematuria, nocturia and suprapubic pain.
Differential diagnosis:
· N10: Acute pyelonephritis
· 03: Infections of the kidney in pregnancy, third trimester – Female pyelonephritis patients often need early treatment. Sepsis, acute renal failure, severe respiratory distress, preterm birth, low birth weight, fetal growth restriction, and cesarean birth can result from untreated pyelonephritis (Jordan et al., 2019. P 674).
· Pertinent positive: urinary frequency and dysuria.
· Pertinent negative: fever, CVA tenderness, chills, myalgia, anorexia, nausea, vomiting, and low back pain.
Plan
POC:
· Urine dipstick to r/o urinary infection – Positive leukocyte esterase and nitrites, negative for blood, glucose or protein.
Labs:
· UA culture to rule out urinary infection, or causative agent.
· CBC, CMP to rule out anemia, infection and
· Rh antibodies (done between weeks 24-28) to determine antibodies for vaccine.
· Glucose Tolerance Test (done between weeks 24-28) to rule out for gestational diabetes.
Diagnostics: Fetal heart tone with doppler 140 bpm.
Medications:
· Rhogam vaccine
· Cephalexin 500 mg PO BID for 7 days, depending on the urine culture results (consider adjusting based on local resistance patterns) (Gupta et al., 2024).
Patient Education:
· Educate patient to take medication as prescribed.
· Educated the patient to seek medical assistance if she develops fever, back pain, or hematuria, which may signal a serious infection.
· Educated patient to hydrate properly to aid expelling urinary tract bacteria
· Educated patient to wipe front to back after using the toilet to prevent entry of bacteria into the urinary tract.
· Educated patient to void frequently to avoid the retention of urine as this inhibits bacterial proliferation into the bladder.
· Educated patient to avoid scented soaps or feminine hygiene sprays that may irritate the urethra hence increasing the risk for a urinary tract infection.
· Educated patient the importance to follow up after the treatment is finished to ensure the effectiveness of the medication.
· Educated patient to eat a balanced healthy diet with plenty of fruits and vegetables to promote health.
· Educated patient to avoid alcohol, tobacco products and caffeine as this can worsen bladder irritation and are not advised to use during pregnancy (Gupta et al., 2024).
Follow up/referral:
· Patient to return in 1 week time for lab results and reassessment of plan of care.
Health maintenance:
· Annual physical due in March 2025.
· Flu vaccine due in October 2025.
· Annual vision screening due in January 2025.
· Annual dental screening due in January 2025.
References:
Jordan, R. G., Farley, C. L., & Grace, K. T. (2019). Prenatal and postnatal care: a woman-centered approach. John Wiley & Sons, Inc. https://online.vitalsource.com/reader/books/9781119318361/epubcfi/6/48%5B%3Bvnd.vst.idref%3DAc13%5D!/4/2/18/4%5Bhead-2-163%5D/2
Gupta, K. (2024). Patient education: Urinary tract infections in adults (Beyond the Basics). UpToDate. https://www.uptodate.com/contents/urinary-tract-infections-in-adults-beyond-the-basics?search=uti+pregnancy+treatment&topicRef=8065&source=see_link
Gupta, K. (2024b). Urinary tract infections and asymptomatic bacteriuria in pregnancy . UpToDate. https://www.uptodate.com/contents/urinary-tract-infections-and-asymptomatic-bacteriuria-in-pregnancy?search=uti+pregnancy+treatment&source=sear
Kristine
Subjective
The patient, Tonia, an 18-year-old female, came with complaints of two months of amenorrhea. She says that her pregnancy test was positive, and according to her LMP, she is 5.6 weeks pregnant. She says she has had light bleeding for the past three days; it was scanty but turned to brown spotting today and has a mild flow like a period. She says she has no pain or cramping and wants to continue with the pregnancy.
Additional questions regarding HPI
1. What was the first day of your last menstrual period (LMP)?
2. Have you had significant weight changes, fatigue, nausea, or vomiting?
3. Any history of pelvic infections, sexually transmitted infections, or surgeries?
4. Have you experienced any other unusual symptoms, such as dizziness or lightheadedness?
Medical questions
1. Medical History Questions
2. Do you have any chronic medical conditions, such as diabetes, hypertension, or thyroid disorders?
3. Have you had any previous pregnancies or miscarriages?
4. Are you currently taking any medications, including birth control or supplements?
Social History Questions
1. Are you sexually active?
2. Do you use any form of contraception?
3. Do you smoke, drink alcohol, or use any recreational drugs?
4. What is your support system like at home?
Objective
Physical Exam
· General Appearance: Assess for signs of discomfort.
· Vital Signs: Measure blood pressure, heart rate, temperature, and respiratory rate. Monitor for any abnormal findings.
· HEENT: Check for any signs of dehydration, pallor, or swelling.
· Cardiovascular: Auscultate heart sounds for any abnormal rhythms or murmurs.
· Respiratory: Assess lung sounds and respiratory effort.
· Abdomen: Check for any tenderness or masses.
· Pelvic Exam: Perform a pelvic examination, if indicated, to check for signs of infection, bleeding, or other abnormalities.
· Extremities: Check for swelling, varicosities, or signs of deep vein thrombosis.
· Neurological: Assess reflexes, coordination, and any signs of preeclampsia.
Tests Ordered
· Serum HCG: First result of 1200, confirming pregnancy.
· Transvaginal Ultrasound: To confirm gestational age, rule out ectopic pregnancy, and assess for fetal heartbeat.
· CBC: To assess for anemia or infection, which can cause complications in pregnancy.
· Blood Type and Rh Factor: To assess for Rh incompatibility.
· STI Screening: Chlamydia, gonorrhea, syphilis, and HIV.
· Urine Culture: To check for urinary tract infections that are common in pregnancy.
Assessment/Diagnosis
Presumptive Diagnosis
Early Pregnancy (5.6 weeks gestational age): Positive pregnancy test and amenorrhea, confirming pregnancy.
Threatened Miscarriage: Light bleeding without pain could suggest a threatened miscarriage, but continued monitoring is necessary to assess fetal viability.
Differential Diagnoses
Ectopic Pregnancy: Lack of severe pain as well as the presence of bleeding makes it improbable for this diagnosis nevertheless, it cannot be eliminated and should be confirmed by means of an ultrasound.
Molar Pregnancy: While rare, this condition can cause abnormal bleeding and elevated hCG levels.
Follow-Up HCG Result (550)
A drop in hCG from 1200 to 550 suggests a possible miscarriage (Yang et al., 2023). This may indicate a non-viable pregnancy, such as a missed miscarriage or blighted ovum, and further evaluation is needed.
Plan
Explanation of HCG Results
I will explain that the decrease in HCG is concerning as it suggests that the pregnancy may not be viable.
Treatment Guidelines and Side Effects
If the miscarriage is confirmed, treatment may include:
Expectant management: Allowing the body to pass the pregnancy naturally can take time.
Medical management: Prescribing Misoprostol to help expel the pregnancy tissue.
Surgical management: In cases where the miscarriage does not resolve with other methods.
Possible side effects of Misoprostol include cramping, bleeding, nausea, and diarrhea.
Partner Notification
Advise the patient to inform her partner about the possible miscarriage so they can provide emotional and physical support.
Follow-Up Care
I will schedule a follow-up appointment in 1-2 weeks to repeat hCG levels and perform another ultrasound to assess the outcome of the pregnancy.
Patient Education
· Sexual Activity: Delay sexual intercourse until the bleeding has subsided and the results of the pregnancy test at the follow-up appointment are known.
· Contraception: Depending on the result of the pregnancy, we can actively plan for contraception after childbirth through the use of IUDs, implants, and pills.
· Trying to Conceive Again: After the completion of the miscarriage and when the patient’s menstrual cycle recurs, she can try to get pregnant again. Support during this process will be provided nationally, and the patient will be given information on the potential risks of further pregnancies.
References
Soper, J. T. (2021). Gestational Trophoblastic Disease. Obstetrics & Gynecology, 137(2), 355–370.
