Eloise Case

Eloise Case

Patient Introduction

Eloise is a 17 year old Italian female, healthy appearing but is nervous in nature.

History of Present Illness: She presents to the office complaining of fatigue, nausea and vomiting for several weeks but seems to be getting worse. No fever, no sick contacts, no stomach ache or diarrhea. Eloise becomes teary eyed as she is nervous about what might be happening.

  • Allergies: PCN
  • Past Medical History: Asthma
  • Medication: Pro-air inhaler 90 mcg/act. Aeros. 2 puffs every four hours as needed
  • Family Medical History: Negative
  • Surgical History: Negative
  • Gynecology History: Menarche is 12 x 29-30 x 4, normal flow, no cramps or heavy bleeding. She reports her cycles are every 2 9-30 days but that her last menstrual cycle was three months ago. She is sexually active with her 17 year old boyfriend, they occasionally use condoms. Patient has not told parents she is sexually active.
  • Obstetrical History: Gravida 0, Para 0
  • Social History: Eloise is a junior in high school on HMO insurance. She lives with her parents and her younger sister and brother. No tobacco, drugs, or alcohol
  • Module 2:

    In this module, you will review Eloise’s record and complete the risk assessment table based on the information you have about your patient at her 12 week initial prenatal visit. Include the appropriate testing for this patient, patient education, anticipatory guidance and treatment options, if needed.

  • Module 6:

    In this module, you will review Eloise’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

    Eloise returns for her 16 week prenatal visit. Her blood pressure is 122/76. She weighs 126 lbs. Fetal heart tones are 135 bpm (beats per minute). She reports no vaginal bleeding, discharge or contractions. Eloise’s fundal exam is consistent with a 16 week gestation at halfway between the pubic hairline and the belly button. She does not report quickening. Eloise continues to feel fatigued during the day. She complain of lightheadedness and shortness of breath. Her sequential screen from her initial prenatal visit was normal.

    Laboratory: HGB 10.1/HCT 32.4, MCV 85, MCH 28, MCHC 34, Platelets 212,000

  • Module 10:

    In this module, you will review Eloise’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.

    30 week prenatal visit

    Eloise returns to clinic at 30 weeks. Her blood pressure is 138/90. She weighs 130 lbs. Fetal heart tones are 138 bpm. Her fundus measures 29 cm. She reports positive fetal movement, no vaginal bleeding, discharge or contractions. Her urine dip is neg for protein, glucose and nitrates. Eloise indicates she is taking her vitamins and iron as prescribed. Mild pedal edema noted on examination. She reports no headache, nausea or vomiting. Eloise's 1 hour glucose tolerance test was done at her last visit and her result is 92 mg/dl. CBC done last visit returned HGB 11.0/HCT 34.2.

    Laboratory: AST: 16 u/l ALT: 34 u/l Uric Acid: 3.2 mg/dL Fibrinogen: 367 mg/dL

  • Module 11:

    In this module, you will review Eloise’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.

    34 week prenatal visit

    Eloise returns to clinic at 34 weeks. Her blood pressure is 138/96. She weighs 132 lbs. Fetal heart tones are 132 bpm. Her fundal height measures 30 cm. She reports positive fetal movement, no vaginal bleeding, discharge or contractions. Urine dip is trace protein, no glucose and no nitrates. She has plus two pedal edema. She reports no headache, nausea or vomiting.

    Laboratory: AST: 20 u/l ALT: 43 u/l Uric Acid: 3.1 mg/dL Fibrinogen 355 mg/dL 24 hour urine protein 58 mg/d

    Ultrasound: Cephalic position, EFW is 1637 grams (<10%), AFI 5cm, Placenta is posterior, fundal grade 1, 3 vessel cord.

  • Module 15:

    In this module, you will review Eloise’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

    Eloise returns to clinic for a 36 week visit. Her blood pressure is 150/100. She weighs 142 pounds. Fetal heart tones are 128 bpm. Fundal heights measures 32 cm. She reports decreased fetal movement, no vaginal spotting and no contractions. Urine dip is 1+ protein, no glucose and no nitrates. She has plus two pedal edema and facial swelling. She reports headache and mild nausea. Reflexes are 2 + bilateral with negative clonus. Her GBS swab came back positive from her last visit.

Initial Physical Exam

  • Wgt: 118 lbs. Height: 5-4 VS 98.6-84-16-120/62
  • General appearance: alert, no acute distress, nervous appearing
  • 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: 98 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: symmetrical, small in 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. Top of the fundus can be felt one finger breadth above symphysis pubis,
  • Extremities: no clubbing, cyanosis, edema or deformities noted. Full range of motion in all joints warm to touch, good capillary refill
  • External genitalia: Tanner V, 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
  • Cervix: nulip, normal and posterior, 4cm, no cervical motion tenderness, no lesions
  • Uterus: is smooth, mobile, non-tender, measuring about 12 weeks size, adnexa is normal, no masses non-tender
  • UCG positive
  • Urine Dip: SG 1.030, 1 + ketones, neg protein, leukocytes, glucose or nitrates

Initial Laboratory

  • CBC: Hbg 10.8, HCT 34.3, platelets 218
  • Hgb Electrophoresis: A1-97.2, A2 2.8
  • Blood Type: O positive, antibody neg
  • TSH: 3.8
  • Rubella: immune
  • Varicella: non-immune
  • RPR: non-reactive
  • Chlamydia: negative
  • Gonorrhea: negative
  • Urinalysis SG: 1.030, 1+ ketones, negative protein, glucose, nitrates, leukocytes neg
  • Hepatitis A: negative
  • Hepatitis B: HBSAb neg, HBSag negative
  • Hepatitis C: negative
  • Cystic Fibrosis Negative