Week 7 Discussion Forum

Select one of the following case studies to address. In the subject line of your post, please identify which prompt you are responding to, for example, #1 Maria, 49-year-old female, annual exam.

Discuss what questions you would ask the patient, what physical exam elements you would include, what further testing you would want to have performed, differential and working diagnosis, treatment plan, including inclusion of complementary and OTC therapy, referrals and other team members needed to complete patient care.

Use at least one scholarly source other than your textbook to connect your response to national guidelines and evidence-based research in support of your ideas. 

In your peer replies, please reply to at least one peer who chose a different case study.

1. Beth,a 33-year-old female who is 14 weeks pregnant is your next patient. As you review her medical record this is what you find:

Past medical history (per paperwork completed prior to first prenatal appointment):

• Eating disorder in adolescence
• Body mass index (BMI): prepregnancy 18.4 (107 lbs, 64 in.)
• Two early miscarriages 3 months ago and 9 months ago. This is her third pregnancy and farthest along she has been (14 weeks)

This is the first time you are seeing this patient. She saw your practice partner last visit and he included these notes related to the patient’s medical and social history:

• One in-patient hospitalization for anorexia nervosa (AN) followed by outpatient counseling throughout teen years       
• Weight loss via excessive exercise and dietary restriction as a teenager
• Amenorrhea for some time, patient unable to quantify
• Relapse when entered college, began bingeing and purging
• Low BMI at time of conception but relatively stable ×10 years

The medical technician shares her data for today: At week 14, no weight gain (107 lb). Blood pressure within normal limits. Complains of nausea with some emesis.

• What is your first concern when you approach treatment of this patient, and why?
• What are the three most important pieces of information in her history, as it relates to her nutritional status and lifelong anorexia nervosa (AN), that you need to evaluate and discuss with this patient?

Provide evidence from the research to support your decision-making.

2. Oliviais a 23-year-old pregnant female at 35 weeks EGA who has been receiving routine prenatal care throughout her pregnancy  and now comes to the clinic complaining of relentless itching all over her body that started in the palms of her hands.  Upon physical examination, you note no obvious rash, just some mild excoriations from Olivia scratching herself.  Olivia denies other symptoms or complaints.  FH is 34 cm, FHR 158, and all VS are WNL.

• What will you include in your differential diagnoses, and what test(s) will you order to help ascertain the correct diagnosis?
• Write a brief summary of the pathophysiology of this diagnosis and the evidence-based guideline recommendations for management.

Provide evidence from the research to support your decision-making.

3. Estellais a 40-year-old woman, married, mutually monogamous with her husband, a G4/T1P1A2L2, and has a BMI of 30. She had gestational diabetes with two of her previous pregnancies that resulted in live births. She is constantly struggling to control her weight and does not feel that she has time to exercise. Her first baby was born at 34 weeks due to preterm labor and her second baby was delivered at term; but she had to have cesarean section delivery due to cephalopelvic disproportion (CPD) and a large for gestational age (LGA) infant. Her past obstetric history is positive for one elective abortion at 14 weeks and one spontaneous abortion (SAB) at 6 weeks gestation. Both of her children are healthy. Estella would like to have another baby. However, she and her husband cannot afford a third baby just yet. She has a history of irregular menses and has been using condoms and withdrawal for birth control.

• If Estella were to become pregnant, which health conditions will she and/or her baby be at risk of, and why?
• What strategies would help to reduce her preconception health risks for gestational diabetes and other potential complications?

Provide evidence from the research to support your decision-making.