Adeline Case

Adeline Case

Patient Introduction

24-year-old Jewish single female. Patient is it a G 5 P 2022 and has private insurance. HPI: presents to the office with amenorrhea 8 weeks ago. She did have an ultrasound done two weeks ago in the ER which is where she found out she was pregnant. The ultrasound was normal with the crown rump length that was consistent with six weeks three days.

  • HPI: Patient presents to the office today with amenorrhea times seven weeks and the UCG pregnancy test in the office is positive.
  • Allergies: None
  • Past Medical History: syncope, SVT and has a history of abnormal Pap smear high-grade SIL, She is positive for HPV.
  • Medications: none
  • Surgical History: LEEP excision 3 years ago
  • Family Medical History: Family history is consistent for diabetes and breast cancer in her mother
  • Gynecological History: Menarche at age 14 with a frequency of every 28 days and duration of 3 to 5 days, moderate flow. Last menstrual period was 8 weeks ago.
  • Obstetric History: Her obstetrical history includes an early miscarriage when she was 15. Vaginal delivery at age 16 at 37 weeks, 5 pound infant girl. Patient had preterm labor at 20 week but was controlled with bedrest. She had a normal spontaneous vaginal delivery with an epidural. At age 20 she underwent a second trimester therapeutic termination with no complications
  • Social History: She lives with her current boyfriend of two years who is the father of this baby and is very supportive. She works 32 hours a week at KinderCare Preschool. She has history of tobacco use (1ppd), no substance no alcohol
  • Module 1:

    In this module, you will review Adeline’s record and complete the risk assessment table based on the information you have about your patient at her 8 week initial prenatal visit. Include the appropriate testing for this patient, patient education, anticipatory guidance and treatment options if needed.

  • Module 3:

    In this module, you will review Adeline’s prenatal visit. Using the risk assessment table please identify any new risks and include the appropriate testing for this patient, patient education, anticipatory guidance and treatment options, if needed, for current or previous risks and routine matters.

    16 week prenatal visit

    Adeline returns to clinic at 16 weeks. Her blood pressures is 116/60. She weighs 134 lbs. Fetal heart tones are 160 beats per minute. She reports no vaginal bleeding, discharge or contractions. Urine dip shows trace protein, no nitrates, no glucose. Fundal height is mid position between the umbilicus and symphysis pubis. Adeline missed her sequential screen appointment. She is smoking 3/4 a pack per day.

  • Module 7:

    In this module, you will review Adeline’s prenatal visit. Using the risk assessment table please identify any new risks and include the appropriate testing for this patient, patient education, anticipatory guidance and treatment options, if needed, for current or previous risks and routine matters.

    24 week prenatal visit

    Adeline returns to clinic at 24 weeks. Her blood pressure is 118/65. She weighs 144 lbs. Fetal heart tones are 155 beats per minute. Fundal exam is 26 cm. Urine dip negative for protein, glucose, nitrates. She reports cramping, light vaginal bleeding and yellow discharge. She continues to smoke. She is still with her current boyfriend in a monogamous relationship. no vaginal odor, itching or irritation, no urinary frequency or dysuria.

  • Module 14:

    In this module, you will review Adeline’s prenatal visit. Using the risk assessment table please identify any new risks and include the appropriate testing for this patient, patient education, anticipatory guidance and treatment options, if needed, for current or previous risks and routine matters.

    36 week prenatal visit

    Adeline returns to clinic at 36 weeks. Her blood pressure is 122/72, she weighs 155 lbs. Fetal heart tones are 145 bpm. Fundal heart is 39 cm. She reports no bleeding, contractions of vaginal discharge. She informs you that an outbreak of fifths disease has occurred at the daycare. She is still smoking but trying to stop. she is excited about the baby coming.

Initial Physical Exam

  • WGT: 124 lbs. Height 64 inches VS 98.4, 76, 16, 100/60
  • General appearance: alert, no acute distress, well hydrated, well developed and well-nourished
  • Neuro: oriented to all spheres, affect and mood is appropriate
  • Head: atraumatic, normocephalic
  • Ears: no external deformities, gross hearing intact
  • Eyes: no external deformities, gross vision intact
  • Nose: no discharge, inflammation or lesions
  • Oral: good dentition, no erythema, exudate, lesions. Tongue protrudes midline, positive gag reflex, uvula rises midline with phonation
  • Neck: trachea midline, no lymphadenopathy
  • Cardiac: 76 regular rhythm, no murmur or gallops
  • Lungs: no respiratory distress, no use of any accessory muscles, lungs are clear to auscultation bilaterally, percussion resonant throughout with symmetrical lung expansion
  • Breasts: are symmetrical medium size, nipples everted, no asymmetry, skin changes, nipple discharge, masses or tenderness. Negative lymphadenopathy
  • Abdomen: non-distended, non-tender, normal bowel sounds in all four quadrants, no hepatosplenomegaly, no hernias.
  • Extremities: no clubbing, cyanosis, edema or deformities noted. Full range of motion in all joints, warm to touch, good capillary refill
  • External genitalia: normal appearance, normal labia majora and minora, no lesions, masses or lymphadenopathy. Urethra is normal with no discharge
  • Internal genitalia: no lesions, adequate pelvic support, no discharge noted
  • Cervix: multip, normal and posterior, no cervical motion tenderness, no lesions
  • Uterus: smooth, mobile, non-tender measuring about 8 weeks size, adnexa is normal, no masses non-tender

Initial Laboratory

  • CBC: Hemoglobin 13.2, hematocrit 38, WBC 7.5, RBC 4.12, platelets 212,000
  • Blood type: O negative, negative antibody
  • TSH: 1.55
  • Rubella: positive
  • RPR: non-reactive
  • Hepatitis B surface antibody positive: antigen negative
  • Hepatitis C antibody negative
  • Hepatitis A antibody negative
  • HIV: negative
  • Varicella: immune.
  • Toxoplasmosis: negative
  • Tay-Sachs: negative
  • Cystic fibrosis: negative
  • Urinalysis: normal
  • Urine culture: negative
  • Gonorrhea culture: negative
  • Chlamydia culture: negative
  • Pap smear: normal
  • Parvo IGM 0.08, IGG 3.73