Tonia is an 18-year-old female who presents to your office complaining of two months of amenorrhea

Tonia is an 18-year-old female who presents to your office complaining of two months of amenorrhea. Her pregnancy test is positive and her LMP indicates she is 5.6 weeks EGA. She reports she has had some bleeding for the past 3 days, that started as spotting, but has continued to be a light period- like bleeding today. She denies any pain. She indicates plans to continue the pregnancy.

Subjective:

Demographic: 18-year-old female, T.; office visit on 3/19/2024

Chief Complaint: Amenorrhea for 2 months. Reported some bleeding for the past 3 days, started as only spotting, but has continue to be light-period-like bleeding today.

HPI: She is an 18-year-old female patient, presented in clinic today with the complain of amenorrhea for 2 months with light spotting last 3 days and now been having more bleeding today. Patient is G0P0; LMP 2/9/2024; Per patient, menarche at the age of 11; She been having regular menstrual periods with moderate bleeding and intermittent abdominal cramps for first 3 days of each menstrual; She been sexually active since the age of 17 without any protection; She had 3 previous sexual partners prior to current partner. No contraception was used in the past including no usage of any condoms. Been having anal and vaginal sex; She was only dating one partner at a time.

Onset: spotting bleeding started 3 days ago, with only spotting, but worsen today

Location: vaginal bleeding

Duration: been getting worst last 3 days

Characteristics: spotting bleeding started 3 days; but worsen today with more of light-period-like bleeding with

Alleviating factors: none

Radiating: none

Timing/Treatment: none; seeing in clinic today due to worsening with

Severity: was spotting started 3 days ago, but worsen today

Obstetric History (ObHx): never had a pap smear nor any pelvic exam. Denies any hx of sexual contact with partners who has hx of STIs; never been tested for STIs. No contraceptive method. Patient’s menarche at the age of 11. Menses were not heavy; normal when they occurred; only used pads and changed about 5-8 pads each day; never used tampons. Had intermittent abdominal cramp for first 3 days of menstrual period. Patient LMP was 2 months ago. without any urination difficulties nor changes in urination. The patient had 3 sexual partners prior to current partner, but only one partner at a time; no one has ever been tested for STIs nor aware of their sexual partners history of STIs. Patient has no known history of any gynecologic issues in the past. Denies dyspareunia. Denise postcoital pain/bleeding. Along with abdominal cramps during menstrual periods, patient had breast pain/tenderness but no lumps nor masses, no nipple discharges. Patient denies any abnormal vaginal discharges since menarche, no foul odor with discharges. There is no known family history of any gynecological issues.

No images/scans been done. No recent hospitalization.

Past Medical History: Denies any past medical history

Allergies: NKDA

Medications: Prenatal vitamin daily; Folic acid 1mg daily, Tylenol 500mg bid PRN headache.

Past Surgical History: tonsillectomy at the age of 7; appendectomy at the age of 10

Family History: She denies any known family history of breast, ovarian, uterine or colon cancer.

Social History: patient denies smoking/drinking alcohol; no recreational drug use. No exercise on a regular basis. Attending local community college for her general education classes.

ROS

GENERAL: No significant recent weight change, No fever

ENDOCRINE: The patient denies any known history of diabetes or thyroid disorders. No known family history of diabetes nor mother ever had gestational diabetes with her pregnancies.

BREASTS: The patient denies any breast lumps, nipple discharge or changes in the skin in the breast area.

RESPIRATORY: Denies Chronic cough, hemoptysis, wheezing, sleep apnea.

CARDIAC: The patient denies chest pain, shortness of breath, syncope. Denies dizziness.

GI: denies tenderness; Bowel sounds present in all 4 quadrants; Normal BMs; no cyclic nor noncyclic pelvic pain; Denies nausea, vomiting, abdominal pain, Rectal bleeding, denies recent change in bowel habits and jaundice

GU: The patient denies hematuria. Been having increased frequency; Denies any urgency. No pelvic pain/pressure with activities;

GYN: G0P0; no dyspareunia; no history of STIs nor with former sexual partners; unprotected sex via anal and vaginal; denies postcoital bleeding/pain; no vaginal discharge changes noted; denies vaginal dryness;

MUSCULOSKELETAL: negative for arthralgias and myalgias, no major joint problems.

NEURO: The patient denies seizure, memory loss, syncope, difficulty with gait or balance, difficulty with speech or coordination.

PSYCH: No problems with anxiety or depression.

Objective:

Vital Signs: BP 115/83 (BP Location: Left arm, Patient Position: Sitting) Pulse 78 | Temp 36.3 °C (97.3 °F) (Temporal) | Resp 17 | Ht 167.6 cm (5′ 6″) | Wt 91.3 kg (201 lb 3.2 oz) | SpO2 98% | BMI 32.47 kg/m²

Physical Findings:

GENERAL: Alert, cooperative, well-groomed, and articulate. No distress.

NECK: Supple, nontender. No thyromegaly or thyroid nodules. Normal carotid upstroke, carotid bruit.

HEART: Normal PMI. Normal S1, S2; no murmurs, rubs, or gallops.

LUNGS: Normal breath sounds, without rales or wheezes. Normal excursions and effort.

ABDOMEN: Mild distended, soft. No hepatosplenomegaly. No masses. Normal bowel sounds. No bruits. RLQ abd mild tenderness upon palpation; on and off discomfort with certain movement; no increase in vaginal bleeding with these pain episodes

GYNECOLOGICAL: pelvic exam done; mild rebound tenderness noted upon palpitation; mild abdominal wall distension noted; some localized abdominal pain without any signs of internal hemorrhage noted; no increased in vaginal bleeding noted upon pelvic exam; I would measure fundal height to double check with 5.6 weeks EGA; beta-HCG confirmed with level of expected;

PELVIC: External genitalia, anus and urethral meatus are normal in appearance and without lesions. I first performed the bimanual examination there is no cervical mass noted upon visual examination.

BIMANUAL EXAM: I will check Hegar’s sign, evaluate for cervical dilation, cervical motion tenderness, adnexal, or abdominal tenderness. As an adnexal mass and mild uterine enlargement are often present with ectopic pregnancy. 50% of the time, there is an adnexal mass. The adnexal mass should be palpated gentl since excessive pressure may rupture an ectopic pregnancy. Enlarged uterus may be present; I would confirm the visualization of an extrauterine gestational sac with a yolk sac or embryo (with or without a heartbeat) on TVUS; There would also be a positive serum hCG and no products of conception on uterine aspiration with subsequent rising or plateauing hCG levels.

PSYCHIATRIC. Normal affect, mood, and behavior. logical thought process. Understand conversation content during the visit

Assessment:

Working/Final Diagnosis: ICD 10: O00.91: Ectopic Pregnancy, Unspecified

Reason for choosing this: Patient prob having the ectopic pregnancy on the right side within the right ovarian tube, as patient was having sign with RLQ abd pain upon palpation; Patient been having vaginal bleeding, started out with spotting for the last 3 days but worsen today.

Differential Diagnosis:

ICD 10: N80.9: Endometriosis

ICD 10: O01.9: Gestational trophoblastic disease

ICD 10: N83.1 Ruptured Corpus luteum

ICD 10: R19.09 Incidental adnexal mass

Plan:

Lab Tests to order

Blood type: O+

Rubella Ab titer: Immune

Antibody screen

Crossmatch if indicated

beta HCG

CBC with diff

PT/PTT

Images:

Ultrasonography: transvaginal and/or abdominal scan

There could be a chance that she might be having a miscarriage as the level of hCG was dropping more than half in 2 days. HCG level is not always definitive, that’s why we have to repeat hCG or TVUS to be done.

Treatment:

General intervention: stabilize maternal condition and treat once confirmed the cause/diagnosis

There could also be dilation and curettage in case of ectopic pregnancy or miscarriage to wait and let it happen on its own.

For patient as she is expected to have an ectopic pregnancy: consult with a physician regarding possible medical management with Methotrexate (MTX) or refer the client to a physician for surgical intervention

The physician may perform culdocentesis to assess for hemoperitoneum

If patient in shock, LR/NS fluid resuscitation.

Medication:

Acetaminophen/Ibuprofen as needed for any discomfort/cramps

Methotrexate is the main agent used. It is a folic acid antagonist that has been used to inhibit the growth of trophoblastic cells. This chemotherapy is also the tx of choice for ectopic pregnancy when surgery is contraindicated, or in the management of postoperative persistent trophoblast.

Follow-Up:

Once the ectopic pregnancy has been removed, the client should be seen in 2-6 weeks for a post-op exam, unless the situation warrants an earlier follow-up visit.

If MTX was used, do serial quantitative HCGs until they return to non-pregnant levels.

Pretreatment testing and instruction for Methotrexate treatment protocols:

hCG concentration

Transvaginal ultrasound

Blood group and RhD typing (with administration of anti-D immune globulin to RhD-negative patients), if indicated

Complete blood count

Liver and renal function tests

Discontinue folic acid supplements

Counsel patient to avoid nonsteroidal anti-inflammatory medications, recommend acetaminophen if an analgesic is needed

Advise patient to refrain from sexual intercourse and strenuous exercise

There are Multiple treatment protocol: I would make sure once if has to do, to use evidence-based protocol

· Single-day protocol

· Two-dose protocol

· Multiple-dose protocol

References:

Detti, L., Francillon, L., Christiansen, M. E., Peregrin-Alvarez, I., Goedecke, P. J., Bursac, Z., & Roman, R. A. (2020). Early pregnancy ultrasound measurements and prediction of first trimester pregnancy loss: A logistic model. Scientific reports, 10(1), 1545. https://doi.org/10.1038/s41598-020-58114-3

Mummert, T. (2023, August 8). Ectopic pregnancy. Stat Pearls [Internet]. https://www.ncbi.nlm.nih.gov/books/NBK539860/

Hashmi, A. M., Bhatia, S. K., Bhatia, S. K., & Khawaja, I. S. (2016). Insomnia during pregnancy: Diagnosis and Rational Interventions. Pakistan journal of medical sciences, 32(4), 1030–1037. https://doi.org/10.12669/pjms.324.10421

Shibboleth authentication request. (n.d.-a). https://www-uptodate-com.westcoastuniversity.idm.oclc.org/contents/ectopic-pregnancy-methotrexate-therapy?search=ectopic+pregnancy+methotrexate&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1

Links to an external site.

Shibboleth authentication request. (n.d.-a). https://www-uptodate-com.westcoastuniversity.idm.oclc.org/contents/ectopic-pregnancy-clinical-manifestations-and-diagnosis?search=ectopic+pregnancy+&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1

Skin conditions during pregnancy. ACOG. (n.d.-a). https://www.acog.org/womens-health/faqs/skin-condi…

Soper J. T. (2021). Gestational Trophoblastic Disease: Current Evaluation and Management. Obstetrics and gynecology, 137(2), 355–370. https://doi.org/10.1097/AOG.0000000000004240

POST 2

Demographic Data

29 year old, Female

Subjective

Chef Complaint: Urinary burning and frequency
History of Present Illness (HPI):

Lisa, a 29-year-old female patient at 28 weeks EGA (G3P2), presents to the clinic for a routine prenatal check-up. Prenatal screenings and vital signs are all within normal limits. Upon assessment, the patient stated that she had been using the bathroom more frequently over the last 2 days. She is aware that at this stage of the pregnancy, she will be using the restroom frequently. However, she states that there is a mild burning sensation when she is urinating and cannot fully empty her bladder. Patient denies pain/fever/chills.

Past Med. Hx (PMH):

Medical History: None.
Surgical History: None.
Hospitalizations: No recent hospitalizations.
Medication: Prenatal Vitamins
Cancer: No cancer history in immediate family
Immunizations: All immunization UTD. Flu denied. COVID x2 (May 2022)

Family Hx:

Mother: Deceased in a car accident. No medical history at the time.
Father: Alive, controlled HTN and HLD.

Father: Social Hx:

Allergies: Pollen. No allergies to medications.
Nutrition:
Exercise: Currently trying to walk 10,000 steps a day.
Substance use: Denies current substance abuse. Patient also denies prior substance abuse.
Alcohol: Currently not drinking alcohol. Patient used to drink 2-3 drinks on the weekends socially.
Tobacco: Denies the use of tobacco/tobacco products.
Occupation: Teacher
Ethnicity: White
Education: Master’s Degree in Education
DV/IPV: The patient states she feels safe at home.

Gynecological Hx:

G:3 P:2

First pregnancy at age 21 ended in miscarriage at 8 weeks.
2nd pregnancy at age 23; full term, vaginal delivery, vacuum assisted, epidural.
3rd pregnancy at age 25; full term, vaginal delivery, epidural.

Miscarriage: 1
Abortion: 0
LMP: 09/05/2023
Rh- Negative.
Labs to Review: CBC, blood type, blood glucose test, urine dipstick.
OB questions to ask:

Any history of preterm labor?
Any history of rupture of membranes?
Did you have a history of gestational diabetes?
Did you have a history of any hypertensive disorders while you were pregnant with your previous pregnancies?
Are there any complications with your previous pregnancies?
Would you like to be vaccinated for Tdap to help protect your newborn from pertussis?

Sexually Active: Heterosexual, monogamous relationship with husband. Sexually active, no condoms.

Review of Systems (ROS):

General: No Acute Distress, denies chills and fever.
Cardiac: Denies chest pain and palpations. Denies swelling in feet and legs.
Respiratory: Denies shortness of breath.
Gastrointestinal: Denies abdominal pain, heartburn, changes in stool.
Genitourinary: Denies vaginal bleeding, denies vaginal odor, and denies painful intercourse. Denies vaginal itching and denies lesions. Frequent urination. Mild Burning when urinating. Urinary retention. Denies flank pain. Denies odor.
Psychiatric: Denies suicidal ideations.

Other relevant questions:

Are there any recent changes in hygiene practices?
Have you been urinating after sex?
Prior to experiencing symptoms, how often were you urinating?
Did you drink water frequently prior to infection?
Is your partner practicing good hygiene?

Objective

Height: 5’7
Weight: 159 pounds
Blood Pressure: 121/74 mmHg
Temperature: 98.1 F
Pulse: 73 bpm
Respiratory Rate: 16 bpm
O2 Saturation: 100%
Pain: 0/10
General: Vital signs within normal range, cooperative and oriented x4.
Respiratory: Good air entry bilaterally, no wheezing and no crackling. No chest wall tenderness, normal percussion. No intercoastal retraction with respirations. Patient is not coughing.
Cardiac: No murmurs, no gallops, and normal s1/s2. No lower extremity edema.
Genitourinary: Pubic hair present. The left Labia majora is slightly elongated compared to the right. No swelling/nodules/or lesions. No redness/swelling is present. The vaginal wall appears red, moist, and without lesions. No cervical lesions or discharge is present. No odor present. Pressure when palpating bladder region.

OBGYN:

Fundal height appropriate for gestational age. No tenderness or guarding upon palpation.

Assessment (Diagnosis/ICD10 Code)
ICD-10 code: N32.81 Overactive bladder

Pertinent Positives: Frequent urination.
Pertinent Negatives: Mild Burning when urinating. Urinary retention.

ICD-10 code: B37.3 Vaginitis due to Candida

Pertinent Positives: Mild Burning when urinating.
Pertinent Negatives: Urinary retention. Frequent urination.

Final Diagnosis: ICD-10 code: N39.0- Unspecified urinary tract infection

Pertinent Positives: Frequent urination. Mild Burning when urinating. Urinary retention.
Pertinent Negatives: –

Plan

POCT:

During diagnosis, based on the patient’s history
Pelvic Exam
Urine Dipstick- Nitrate and leukocyte-positive

Dx Plan:

Urinalysis
Urine culture and sensitivity- determine which pathogen is causing the urinary tract infection.

Tx Plan:

Ceftriaxone 1 gram, IM injection. Quantity:1. Refill: 0

Administered once to jump-start treatment for the UTI to prevent any complications from occurring to the mother and fetus.

Penicillin G 300 mcg, IM injection. Quantity:1. Refill: 0

Prevents Rh isoimmunization in Rh-negative women at 28 weeks gestation.

Cephalexin 500 mg twice daily for 7 days. Quantity: 14. Refill: 0.

Education:

Please complete the entire antibiotic regimen to treat the infection appropriately.
If not adequately treated, the bacteria infection can increase and potentially become resistant, putting you and the baby at risk.
UTI can cause pyelonephritis, preterm labor, and low birth weight if left untreated or treated improperly (Habak & Griggs, 2023).
Continue to increase your fluid intake to help flush bacteria that is present in your urinary tract.
Do not hold in your urine; try to empty your bladder for at least every 4 hours.
Wipe front to back after using the restroom
Urinate after sexual intercourse.
Reduce the risk of introducing new bacteria into your urinary tract infection by asking your partner to shower before intercourse (ACOG, 2024).
Potential side effects include diarrhea, nausea, vomiting, yeast infection.
Look out for potential signs of yeast infection, including thick-white vaginal discharge, itching, vaginal irritation, and burning sensation. If you experience any of these symptoms; give the office a call for a visit (Herman, 2023).
Irritation of injection site is normal; however if you notice a rash forming or excessive itching in the area along with the rash. Call the office. If it is outside working hours; please visit the nearest emergency room.
Increase intake of cranberry juice or cranberry tablets to help alleviate UTI symptoms.
You should begin to feel better within 24-48 hours after injections and first dosage of oral antibiotics. If you do not feel better or your symptoms get worse please contact the office.
Be aware of signs of kidney infection this includes: fever, chills, body aches, pain in flank area, and decrease in urine production .

Referral/Follow-up:

Schedule a follow-up appointment in 1 week to monitor response to treatment and repeat urine testing if necessary. Make an appointment if symptoms such as fever or worsening do not improve after 24 hours.
If the patient is experiencing worsening symptoms, a high-grade fever, changes in breathing, or changes in consciousness, go to the emergency department

**Problem-focused SOAP Note**

 

**Patient Information:**

– Name: Tonia

– Age: 18

– Gender: Female

– Date of Visit: 3/19/2024

 

**Subjective:**

– **Chief Complaint (CC):** Amenorrhea for 2 months with recent bleeding.

– **History of Present Illness (HPI):** Tonia, an 18-year-old female, presents with amenorrhea for 2 months. She reports light spotting over the past 3 days, which has progressed to light-period-like bleeding today. She denies pain. Tonia is nulligravida (G0P0) with menarche at age 11. She has been sexually active since age 17 without contraception, engaging in both anal and vaginal sex. She has had three previous sexual partners, always monogamous. No history of STIs. No dyspareunia or postcoital bleeding. Menstrual periods were regular with moderate bleeding and abdominal cramps. No history of pelvic exams or Pap smears. No family history of gynecological issues. Denies substance abuse or smoking.

 

**Past Medical History:**

– Surgical: Tonsillectomy at age 7, appendectomy at age 10.

– No significant medical history or allergies.

 

**Family History:**

– No family history of breast, ovarian, uterine, or colon cancer.

 

**Social History:**

– Non-smoker, no alcohol or recreational drug use.

– Attending community college.

– No regular exercise routine.

 

**Review of Systems (ROS):**

– General: No recent weight change, no fever.

– Endocrine: No history of diabetes or thyroid disorders.

– Gynecological: Nulligravida, no dyspareunia, no abnormal discharges.

– No significant findings in other systems.

 

**Objective:**

– Vital Signs: BP 115/83 mmHg, HR 78 bpm, Temp 36.3°C, RR 17 bpm, SpO2 98%, BMI 32.47 kg/m².

– Physical Exam: Abdomen mildly distended, RLQ tenderness, pelvic exam reveals mild rebound tenderness, no cervical masses, or adnexal masses palpated.

 

**Assessment:**

– **Diagnosis:** Ectopic Pregnancy (ICD 10: O00.91).

– **Differential Diagnoses:**

Endometriosis (ICD 10: N80.9)
Gestational trophoblastic disease (ICD 10: O01.9)

– **Final Diagnosis:** Ectopic Pregnancy based on clinical presentation and positive beta-HCG.

 

**Plan:**

– **Lab Tests:** Beta-HCG, CBC, PT/PTT, transvaginal ultrasound.

– **Imaging:** Transvaginal and/or abdominal ultrasound.

– **Treatment:** Consultation with a physician for possible Methotrexate therapy or surgical intervention.

– **Medication:** Pain management with acetaminophen, consider Methotrexate if indicated.

– **Follow-up:** Repeat beta-HCG levels, post-op exam if surgical intervention required.

 

**References:**

– American College of Obstetricians and Gynecologists. (n.d.). Skin conditions during pregnancy. Retrieved from https://www.acog.org/womens-health/faqs/skin-condi…

– Detti, L., Francillon, L., Christiansen, M. E., Peregrin-Alvarez, I., Goedecke, P. J., Bursac, Z., & Roman, R. A. (2020). Early pregnancy ultrasound measurements and prediction of first trimester pregnancy loss: A logistic model. Scientific reports, 10(1), 1545. https://doi.org/10.1038/s41598-020-58114-3

– Mummert, T. (2023). Ectopic pregnancy. Stat Pearls. Retrieved from https://www.ncbi.nlm.nih.gov/books/NBK539860/

– Soper J. T. (2021). Gestational Trophoblastic Disease: Current Evaluation and Management. Obstetrics and gynecology, 137(2), 355–370. https://doi.org/10.1097/AOG.0000000000004240

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