Audio Transcript Auto-generated
- 00:01 - 00:02
Yeah. Hi my name's Crystal Martin.
- 00:03 - 00:05
And this is my case study presentation on a patient
- 00:06 - 00:09
that I saw in women's health mm.
- 00:11 - 00:14
And this is for nursing 6 45 caring for women.
- 00:16 - 00:18
And the due date is October 10- 2021.
- 00:20 - 00:22
So my patient's name was cm.
- 00:22 - 00:26
And she was an african american female who was 27
- 00:26 - 00:26
years old.
- 00:27 - 00:29
And at the time of the visit she weighed 100
- 00:29 - 00:29
and £25.
- 00:30 - 00:33
Her allergies included penicillin.
- 00:34 - 00:36
And when she did take penicillin she developed a rash.
- 00:37 - 00:39
Um The medications that she were on she was on
- 00:39 - 00:44
was smarty pants, prenatal gummies, iron supplement 65 mg.
- 00:45 - 00:49
Maio de charo which is a supplement for women with
- 00:49 - 00:51
pcos that she found online.
- 00:51 - 00:56
And then also mono mac 100 mg capsules um That
- 00:56 - 00:59
she was currently taking prescribed to her by her O.
- 00:59 - 00:59
B. G.
- 00:59 - 00:59
Y. N.
- 01:02 - 01:04
So some subjective data about my patient.
- 01:04 - 01:07
Her chief complaint was she was coming in due to
- 01:07 - 01:10
dark brown to bright red spotting and bleeding for the
- 01:10 - 01:11
past two days.
- 01:13 - 01:16
History of presenting illness includes see him as a 27
- 01:16 - 01:19
year old eight week pregnant patient G.
- 01:20 - 01:20
Two P.
- 01:20 - 01:21
Zero T.
- 01:21 - 01:22
Zero A.
- 01:22 - 01:22
Zero L.
- 01:23 - 01:26
Zero presenting with dark brown to bright red vaginal bleeding
- 01:26 - 01:27
for the past two days.
- 01:27 - 01:30
She stated that she went to the er sunday morning
- 01:31 - 01:33
when she first noticed a dark brown blood percy.
- 01:33 - 01:35
Um She was told that they could not find the
- 01:35 - 01:36
source of bleeding.
- 01:36 - 01:39
Um And she was sent home after an ultrasound showed
- 01:39 - 01:40
a viable pregnancy.
- 01:40 - 01:44
She had been experiencing some mild cramping and she associated
- 01:44 - 01:45
that with the pregnancy.
- 01:46 - 01:48
And um no fevers, chills or recent trauma.
- 01:49 - 01:52
She denies any recent sexual activities for the past week.
- 01:55 - 01:57
Her family history included.
- 01:57 - 01:59
Her father has a diagnosis of A.
- 01:59 - 01:59
D. H.
- 01:59 - 02:02
D. Her mother deals with allergies and asthma.
- 02:03 - 02:04
No other family history was reported.
- 02:05 - 02:08
Her family um unit includes her husband to dogs.
- 02:08 - 02:10
And during the day she works as a nurse at
- 02:10 - 02:14
a local pediatric office and there's no smoking in or
- 02:14 - 02:14
outside of the home.
- 02:17 - 02:20
Her immunizations were up to date and the rest of
- 02:20 - 02:24
her medical history was um un remarkable.
- 02:25 - 02:27
And we already went through her current medication and her
- 02:27 - 02:33
allergies. So some subject of data when it came to
- 02:33 - 02:36
her review system, she denied feverish chills or anorexia.
- 02:37 - 02:40
She denied anything with her ears, nose throat um eye
- 02:40 - 02:42
redness, anything like that.
- 02:42 - 02:44
She also said she did not have any headaches, dizziness,
- 02:45 - 02:46
seizures or coordination issues.
- 02:47 - 02:51
Um But for gastro urinary she denied in contents this
- 02:52 - 02:52
area here materia.
- 02:53 - 02:55
But she did say that she's been having some urinary
- 02:56 - 03:00
frequency. And she's on day seven of antibiotics treatment for
- 03:00 - 03:00
a U.
- 03:00 - 03:01
T. I.
- 03:03 - 03:03
Um G.
- 03:04 - 03:04
I. Y.
- 03:04 - 03:06
She denied any abdominal pains.
- 03:07 - 03:13
Besides the cramping that she associated with pregnancy vomiting, diarrhea,
- 03:13 - 03:16
constipation. Um And everything else.
- 03:17 - 03:23
Her musculoskeletal dermatology in cardiovascular exam was grossly normal or
- 03:23 - 03:26
for her review system in the Quran um was also
- 03:26 - 03:28
normal uh for O.
- 03:28 - 03:28
B. G.
- 03:29 - 03:29
Y. N.
- 03:30 - 03:32
She was positive for bleeding and spotting for the past
- 03:32 - 03:35
two days and she denied any odor or discharge odor
- 03:36 - 03:36
to her discharge.
- 03:37 - 03:41
Her vaginal discharge denies any bleeding disorders or lymph nodes
- 03:41 - 03:42
that were in large.
- 03:42 - 03:46
Um She was a little bit congested and had mentioned
- 03:46 - 03:49
that she had a slight cough um and denied any
- 03:49 - 03:50
wheezing and shortness of breath.
- 03:51 - 03:53
She denied anxiety, insomnia, mood changes.
- 03:54 - 03:56
But she did say that she had some sleep change
- 03:56 - 03:59
present that she associated with normal pregnancy.
- 04:01 - 04:05
So her object objective data and her vitals are as
- 04:05 - 04:09
followed and they were all within normal limits upon physical
- 04:10 - 04:11
examination generally.
- 04:12 - 04:12
She was alert.
- 04:13 - 04:15
She was a little bit slowed, Her skin was dry
- 04:16 - 04:16
and intact.
- 04:17 - 04:19
Um There's no evidence of trauma to her head.
- 04:19 - 04:22
Um And her ears, nose and throat, neck.
- 04:23 - 04:25
All of that stuff came back within normal limits.
- 04:27 - 04:29
Her lung exam was normal.
- 04:29 - 04:31
Her heart exam was normal as well as the chest,
- 04:32 - 04:33
her abdominal um exam.
- 04:34 - 04:35
Her abdomen was round and symmetric.
- 04:36 - 04:38
There was no tenderness even with light and hard.
- 04:39 - 04:41
How patient, excuse me.
- 04:42 - 04:44
Um And her bow sounds were within normal limits.
- 04:44 - 04:49
There's no areas of pulsation or masses noted no swelling.
- 04:50 - 04:52
She had full range of motion and no tenderness.
- 04:53 - 04:55
Um And all of her pulses were pal potable and
- 04:56 - 04:59
present during her pelvic examination.
- 05:00 - 05:03
She did have moderate active bleeding um That was no
- 05:03 - 05:05
need from her vagina, but her cervical O.
- 05:06 - 05:06
S. Was closed.
- 05:07 - 05:11
Um There was no tenderness to the area that was
- 05:11 - 05:12
observed upon the public examination.
- 05:13 - 05:16
There was no blood clots or tissues um in her
- 05:17 - 05:17
perry pad.
- 05:18 - 05:22
Um And her the remainder of her physical exam was
- 05:22 - 05:27
unremarkable. So we were able to do some labs just
- 05:28 - 05:29
based off of her presentation.
- 05:30 - 05:33
A urine test uh was done just to confirm the
- 05:34 - 05:34
U. T.
- 05:34 - 05:37
I. Um So she was positive for Lucas sites but
- 05:38 - 05:38
everything else was unremarkable.
- 05:39 - 05:42
Um We did a pregnancy test with urine and that
- 05:42 - 05:46
came back positive for hcG quant levels were drawn and
- 05:47 - 05:50
um during the time of the case they were continuing
- 05:50 - 05:52
to increase when we got the results back.
- 05:52 - 05:54
Her wet swab was in progress.
- 05:55 - 05:56
Her blood type was o positive.
- 05:57 - 05:58
We did blood work.
- 05:58 - 06:01
Um In her cervical gonorrhea and chlamydia culture.
- 06:02 - 06:04
Once we received the web swab back were negative.
- 06:06 - 06:09
Um The rest of her labs were pretty normal.
- 06:10 - 06:13
Um She was negative for group B.
- 06:13 - 06:14
Herpes hep C.
- 06:15 - 06:16
Her pop singer was normal.
- 06:16 - 06:18
Her PPd was not done.
- 06:18 - 06:20
Um An HIV test was negative.
- 06:22 - 06:24
The one procedure that we did do on this patient
- 06:24 - 06:27
at the time um was an ultrasound and this was
- 06:27 - 06:29
an ultrasound done before 14 weeks of pregnancy.
- 06:30 - 06:33
So it's a trans vaginal ultrasound and that ultrasound showed
- 06:34 - 06:37
what appeared to be a normal gestational chat sack within
- 06:37 - 06:38
the Uterus.
- 06:38 - 06:41
With a fetus that had a fetal heart rate of
- 06:41 - 06:43
156 beats per minute.
- 06:44 - 06:47
And the crown to rim length was consistent with the
- 06:47 - 06:48
patient's gestational age.
- 06:51 - 06:55
The first differential diagnosis was idiopathic bleeding in a viable
- 06:56 - 07:00
pregnancy. So typically this can produce some cramping and bleeding.
- 07:01 - 07:04
But how why it's idiopathic is because the cervical OS.
- 07:05 - 07:06
Is remains closed.
- 07:07 - 07:09
It's not uncommon for women to have this after sexual
- 07:09 - 07:14
intercourse after pap exam or public examination if she was
- 07:14 - 07:14
in the E.
- 07:14 - 07:18
D. On sunday and now is experienced for brown blood
- 07:18 - 07:21
and now is experiencing the red bright red blood that
- 07:22 - 07:23
could also be a cause of that.
- 07:23 - 07:26
Um And some woman who experienced this type of bleeding
- 07:26 - 07:28
go on to deliver healthy babies.
- 07:29 - 07:33
So the speculum examination was performed and there was no
- 07:34 - 07:36
products of conception found in the cervical Os.
- 07:37 - 07:41
Uh The ultrasound showed a viable uh pregnancy and the
- 07:41 - 07:45
ultrasound that was done in the emergency room actually showed
- 07:45 - 07:49
a fetal heart rate on of 1 71 on examination.
- 07:50 - 07:55
Um And the baby was measuring correctly which is why
- 07:55 - 07:57
this differential diagnosis is appropriate for this patient.
- 07:59 - 08:01
So the plan based off of this diagnosis is to
- 08:01 - 08:05
continue to push patient to drink lots of fluids, patient
- 08:05 - 08:07
was asked to be on pelvic rest for two weeks.
- 08:07 - 08:10
Um We also looked at putting her on progesterone.
- 08:11 - 08:15
Suppository um supplement if the bleeding continued at this time
- 08:15 - 08:17
patient refused to supplement.
- 08:18 - 08:20
Um But we did talk about the benefits of that.
- 08:20 - 08:22
Since she did have some idiopathic bleeding.
- 08:22 - 08:27
Um And she was willing to discuss that if the
- 08:27 - 08:31
bleeding continued in the pregnancy continued to be viable um
- 08:31 - 08:32
at the next recheck appointment.
- 08:33 - 08:35
So she we did make a recheck appointment for two
- 08:35 - 08:36
weeks from now.
- 08:36 - 08:39
And she was instructed to report any heavy bleeding or
- 08:39 - 08:43
cramping and to continue with her regular prenatal care visits.
- 08:45 - 08:48
The next diagnosis was threatened miscarriage prior to 20 weeks
- 08:49 - 08:49
of gestation.
- 08:49 - 08:52
So typically women are at risk of having a miscarriage
- 08:53 - 08:56
before um are at the highest risk of miscarriage before
- 08:57 - 08:58
the 1st 12 weeks.
- 08:59 - 09:02
So in the first trimester but threatened vaginal bleeding is
- 09:03 - 09:06
also vaginal bleeding during um pregnancy.
- 09:06 - 09:10
That does not mean meat diagnosis criteria for spontaneous abortion
- 09:10 - 09:12
because there was a viable pregnancy found.
- 09:13 - 09:17
Um So any pregnancy related bloody vaginal discharge or frank
- 09:18 - 09:21
bleeding during the first half of pregnancy without cervical dilation
- 09:22 - 09:28
can um meets the criteria for this differential diagnosis and
- 09:29 - 09:33
this can be present in early pregnancy with laura abdominal
- 09:34 - 09:36
pain and vaginal bleeding for this patient.
- 09:37 - 09:41
This was evidenced by the fetal fetal fetal activity.
- 09:41 - 09:42
Excuse me.
- 09:42 - 09:43
Um The O.
- 09:43 - 09:44
A. O.
- 09:44 - 09:47
S. That was closed and then the normal HCG levels
- 09:47 - 09:50
that were noted not only the 1 71 heart rate
- 09:50 - 09:53
in the emergency room but the fetal heart rate that
- 09:53 - 09:58
was found in the visit um that we did and
- 09:58 - 10:01
that was a little bit lower but still a viable
- 10:01 - 10:04
pregnancy and also the fact that the crown to rim
- 10:04 - 10:07
length was within gestational parameters.
- 10:09 - 10:13
Um So the plan of care for that was no
- 10:13 - 10:16
different from the plan of care uh For the first
- 10:16 - 10:19
diagnosis which was still pelvic rest, looking into the progestin
- 10:19 - 10:21
and then pushing fluids as well.
- 10:21 - 10:25
Um And we instructed patient to call if the bleeding
- 10:26 - 10:28
became heavier or she started to feel like she was
- 10:28 - 10:29
passing blood clots or tissues.
- 10:31 - 10:33
Um And she was going to be on Um Pelvic
- 10:33 - 10:35
rest for two weeks until we did the recheck appointment
- 10:36 - 10:37
in the office.
- 10:41 - 10:44
So the next diagnosis was uncomplicated UTI.
- 10:44 - 10:47
I. And this is common during pregnancy and the most
- 10:47 - 10:51
common causative agent for this is equally um And pregnancy
- 10:52 - 10:54
increases women at risk for getting a U.
- 10:54 - 10:55
T. I.
- 10:55 - 10:58
And this typically begins around six weeks of gestation And
- 10:58 - 11:01
can peek around week 22- 24 of gestation.
- 11:02 - 11:06
Uh It's due to the increased bladder volume and decrease
- 11:06 - 11:07
bladder tone typically.
- 11:10 - 11:16
So this was evidenced by the positive um house urinary
- 11:16 - 11:20
analysis that had the Lucas sites and um the blood.
- 11:20 - 11:25
But the blood is more associated with the idiopathic bleeding
- 11:25 - 11:26
than it is to use a.
- 11:27 - 11:30
Uh And then the patient has been taking antibiotics and
- 11:30 - 11:31
she's on day seven currently.
- 11:31 - 11:36
Um But her urinary track anatomy was normal in function
- 11:37 - 11:38
based off of our assessment.
- 11:39 - 11:42
Um But because the patient appeared to be well during
- 11:43 - 11:46
the physical examination but the to the um urine tests
- 11:47 - 11:48
showed a trace of illegal sites.
- 11:48 - 11:51
We wanted to go ahead and add this diagnosis in.
- 11:51 - 11:53
Because we're still treating the patient for it and she
- 11:53 - 11:57
hasn't completely cleared the U.
- 11:57 - 11:57
T. I.
- 11:58 - 12:02
Which is evidenced by her being on day seven of
- 12:02 - 12:02
the antibiotics.
- 12:03 - 12:06
So the planet care for this was to have the
- 12:06 - 12:10
patient continue to take the prescribed medication to drink lots
- 12:10 - 12:10
of water.
- 12:11 - 12:14
We educated her on how to empty her bladder completely.
- 12:15 - 12:19
Um Wearing cotton underwear can help decrease the chances of
- 12:19 - 12:20
recurring U.
- 12:20 - 12:20
T. I.
- 12:20 - 12:22
S. Or even prolonging the current U.
- 12:22 - 12:22
T. I.
- 12:23 - 12:26
S. And um just because of pregnancy being a high
- 12:26 - 12:28
her being at higher risk of getting a U.
- 12:29 - 12:29
T. I.
- 12:29 - 12:32
We asked her to avoid wearing underwear at night if
- 12:32 - 12:35
possible and to avoid any harsh shope to the genital
- 12:35 - 12:37
area. She's going to come back in two weeks for
- 12:38 - 12:38
the recheck appointment.
- 12:39 - 12:43
Um And since the antibiotic therapy was not completed we
- 12:43 - 12:48
are planning to recheck her urine during that uh examination
- 12:48 - 12:50
to assure that the U.
- 12:50 - 12:50
T. I.
- 12:50 - 12:51
Has cleared.
- 12:52 - 12:56
And the last differential diagnosis that I had for this
- 12:56 - 12:59
patient is a sub chronic hemorrhage which is the most
- 12:59 - 13:02
common cause of bleeding vaginal bleeding in pregnant patients.
- 13:03 - 13:07
The bleeding um is typically under the crone membrane and
- 13:08 - 13:11
which is what the Koran membrane which is what encloses
- 13:12 - 13:14
the embryo into your uterus.
- 13:15 - 13:19
And it's caused by a detachment of that membrane from
- 13:19 - 13:20
the uterus wall.
- 13:20 - 13:24
And this is evidenced by the light bleeding and the
- 13:24 - 13:25
absence of abdominal pain.
- 13:26 - 13:30
Sharp abdominal pain that would be uh cramp, like if
- 13:31 - 13:31
it was a miscarriage.
- 13:32 - 13:36
And the ultrasound finding actually showed a crescent shaped area
- 13:37 - 13:41
behind the fetal membrane that was elevated um and it
- 13:42 - 13:45
actually elevated part of her placenta, which is how we
- 13:45 - 13:47
got to this diagnosis.
- 13:48 - 13:52
And we offered the progesterone supplement for that and pelvic
- 13:52 - 13:55
rest. At this point there's really nothing as providers we
- 13:55 - 13:58
could do besides continue to monitor it and make sure
- 13:58 - 14:00
it's not getting any bigger pelvic rest and no lifting
- 14:01 - 14:02
for the next two weeks.
- 14:02 - 14:03
It's going to help with that.
- 14:03 - 14:06
And we will do a follow up ultrasound and a
- 14:06 - 14:09
few in that in two weeks to determine if it
- 14:10 - 14:12
has gotten any bigger, um and if it's just still
- 14:13 - 14:15
stable and we'll continue to watch your pregnancy closely.
- 14:18 - 14:21
And here are my references for my presentation today.
- 14:21 - 14:24
Thank you for listening to my case to be presentation