Shannon Case

Shannon Case

Patient Introduction

Shannon is a 35-year-old African American married woman.

History of Present Illness: presents to the office with private insurance with a chief complaint of amenorrhea for 6 weeks. Denies headache, edema, vaginal bleeding or discharge. Patient does have nausea and vomiting for the last week that occurs three times a day. UCG done at home one week ago was positive. Negative urine protein, glucose and nitrates.

  • Allergies: She has no reported allergies.
  • Past Medical History: Past medical history is consistent for infertility; however this pregnancy was achieved spontaneously; HPV, obesity and hypothyroidism.
  • Medications: She takes Valtrex 1 g two tablets by mouth repeated every 12 hours for cold sores and levoxyl 0.125 mg qd.
  • Family Medical History: Family history is consistent for colon cancer - maternal grandfather; diabetes- maternal mother; and hypertension in both the patient's parents
  • Surgical History: None
  • Gynecology History: Menstrual history: menarche at 12 occurring every 36 days lasting seven days. Menstrual history: menarche at 12 occurring every 36 days lasting seven days.
  • Obstetrics History: The patient did have one pregnancy two years ago that resulted in an early spontaneous miscarriage with no complications.
  • Social History: Patient has been married for seven years and works as a business manager full-time. Social history is negative for tobacco, alcohol, and drugs.
  • Module 3:

    In this module, you will review Shannon’s record and complete the risk assessment table based on the information you have about your patient at her 6 week initial prenatal visit. Include the appropriate testing for this patient, patient education, anticipatory guidance and treatment options if needed. (All of the information above should be included in this module)

  • Module 4:

    In this module, you will review Shannon’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.

    7 week prenatal visit

    Shannon returns to the office 1 week later, when she presents with vaginal bleeding x 3 hours, pt. states bleeding started this am, when she got up to go to the bathroom. She reports the bleeding as red, light to moderate in amount. No pain or cramping noted. Weight was 256 lbs. B/P 120/70, negative urine protein, glucose and nitrates; no headache, nausea, vomiting, no edema, vaginal discharge; patient is taking her vitamins.

  • Module 9:

    In this module, you will review Shannon’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.

    29 week prenatal visit

    Shannon returns for her routine prenatal visit at 29 weeks. Since treating her thyroid condition, she has no further bleeding and the pregnancy has been uneventful. Wgt 254, B/P 122/76, urine is 2+ glucose, trace protein, negative ketones. Shannon indicates that she feels the baby move every day, no leaking, bleeding or contractions. She is taking her PNV qd along with the levoxyl 0.25mg. Shannon indicates that she has some white clumpy vaginal discharge that is very itchy, for the past few days. No odor or burning. Fetal heart is 160, Fundal height is 31 cm

    Laboratory: NIPT was normal, AFP 1.60 MoM, Her TSH last visit was 2.4, CBC at 16 weeks was normal, one hour gtt today was 167.

    US: Her sequential screen from earlier in the pregnancy is normal.

    Fetal Survey at 20 weeks was normal.

  • Module 11:

    In this module, you will review Shannon’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.

    33 week prenatal visit

    Shannon returns for a routine prenatal visit at 33 weeks. Wgt is 256, B/P 128/80, FHR is 164 and Fundal height is 36 cm. Shannon indicates she feels the baby move every day and performs her kick counts daily. She is taking her PNV and Levoxyl as ordered. She completed the monistat given a few weeks ago, and has no further symptoms. Shannon had an elevated 1 Hour at her 29 week visit and had a 3 hour gtt. Shannon met with the diabetic educator and endocrinologist and was started on NPH 5 units TID. She is doing home blood glucose sticks with a goal of FBS < 90 and 2 hour postprandial of < 120.

    Laboratory: 3 hour gtt- FBS 98, 1 hour-164, 2 hour-160, 3 hour 135.

    US: Cephalic position, EFW 2812 gr (90%), AFI 21 cm. Posterior fundal grade 2 placenta, 3 vessel cord.

Initial Physical Exam

  • Weight: 258 lbs. Height 65 inches VS 98.4 -84-20-128/74
  • General appearance alert, no acute distress, well hydrated, well developed, obese appearing woman
  • Neuro: oriented to time and place and has appropriate affect and mood.
  • Head: normocephalic, atraumatic.
  • Ears: the Tympanic membranes are intact and clear with normal canals, hearing intact bilaterally.
  • Eyes: normal vision, no discharge, no double vision, blurry vision. Nose: no discharge, inflammation or lesions
  • Mouth: has no deformity or lesions, good dentition, uvula rise midline, tonsils 1+
  • Skin: normal Turgor and color, no rashes, no lesions, no bruising, no edema, normal nails and hair
  • Neck: supple no adenopathy, trachea is midline, no bruits, thyroid normal in size and symmetrical, no nodules palpated
  • Cardiac: 76, regular rhythm, no murmurs or gallops
  • Lungs: no respiratory distress, no use of accessory muscles, lungs are clear to auscultation; symmetrical lung expansion, percussion is resonant throughout
  • Breasts are large and pendulous, symmetrical, nipples are everted, no skin changes, nipple discharge, masses or tenderness; no lymphadenopathy
  • Abdomen: obese, non-distended, non-tender, positive bowel sounds, tympanic throughout, no hepatosplenomegaly noted.
  • External genitalia: normal appearance, normal hair distribution, no lesions or masses
  • Vagina: no lesions, no masses, has adequate pelvic support, the cervix is midline, nullip, with a bluish hue, and no lesions and no cervical motion tenderness
  • Uterus is 6 weeks in size, mobile, non-tender,
  • Adnexa: normal, no masses and non-tender.

Initial Laboratory

  • CBC: Hemoglobin of 13.1, hematocrit 37.6, white blood cell 9.7, red blood cell 4.32, platelets 190,000.
  • Blood type: O positive and negative antibody
  • TSH: 16.76
  • T4: .70
  • Random blood sugar: 102
  • Varicella: immune
  • Rubella: immune
  • RPR: non-reactive
  • Chlamydia: negative
  • Gonorrhea: negative
  • HIV: negative
  • Hepatitis B surface antigen negative; surface antibody positive; Hepatitis C negative
  • Cystic fibrosis: negative
  • Pap within normal limits- negative HPV
  • Urine culture: negative
  • Urinalysis: normal
  • Hemoglobin Electrophoresis: A1 96.3% A2 3.6% F 0.1%