How to address an aquifer case History, Physical Exam, and Assessment sections: 16-year-old female with vaginal bleeding and UCG (Solved)

How to address an aquifer case History, Physical Exam, and Assessment sections: 16-year-old female with vaginal bleeding and UCG (Solved)

DOMAIN: HISTORY: 1a) Identify two (2) additional questions that were not asked in the case study and should have been? 

The first question that should have been asked is about the sexual history of Savannah’s boyfriend. “Has your boyfriend had any sexually transmitted infections that you know of?”

As a teenager, I would have expected the nurse to address the issue of oral and anal sex. “Have you ever had or tried oral and anal sex with your partner?”

1b) Explain your rationale for asking these two additional questions.

Disclosing sexual history is important during health assessment to identify the risk for STDs and other complications. While Savannah reports no history of infection, it is important to understand if her partner has had any serious infections. Some STDs can go unnoticed for long making understanding the partner’s sexual history important (Committee on Adolescent Health Care, 2017). Secondly, oral and anal sexual behaviors are increasingly reported among adolescents and adults. Asking this question could help identify health risks for Savannah like oral candidiasis and anal cancers.

1c) Describe what the two (2) additional questions might reveal about the patient’s health.

Among adolescents, the greatest sexual risk involves contracting STDs and pregnancy among females. Asking the two questions could have helped the provider to identify Savannah’s risk for STDs. Additionally, the questions could help unveil issues like unfaithfulness that could lead to undesirable outcomes among partners. Regarding oral and anal sex, the healthcare provider could have identified possible routes of infection and provided counseling to the patient.

DOMAIN: PHYSICAL EXAM

For each system examined in this case;

2a) Explain the reason the provider examined each system.

Conducting a physical examination is mandatory for all women during the pre-conception visit or during the first pregnancy visit. During Savannah’s visit, she had complaints of abnormal vaginal bleeding following a positive pregnancy test. For instance, reviewing the vital signs for fever, hypotension, and tachycardia can help the provider understand the seriousness of the patient’s health problem. The evaluation focuses on abdominal and pelvic examination to confirm if the pregnancy is intact and to guide further investigation. Savannah’s physical exam focused on general appearance, cardiovascular stability, abdominal examination, and pelvic assessment to ascertain the causes and severity of bleeding.

2b) Describe how the exam findings would be abnormal based on the information in this case. If it is a wellness visit, based on the patient’s age, describe what exam findings could be abnormal.

During the examination, the patient appeared anxious probably due to the abnormal vaginal bleeding. On pelvic examination, a minimal amount of fresh blood was observed in the posterior fornix. Availability of blood indicated that there was abnormal activity in the uterus that could be confirmed by other diagnostic tests.

2c) Describe the normal findings for each system.

The patient’s vitals were as follows: Temperature 37.2°C, pulse 85 beats/ minute, and blood pressure 98/66 mmHg. These vitals were within the normal range indicating that the patient’s bleeding was mild. She also expressed that she did not experience headaches, dizziness, or blurred vision that could indicate excessive blood loss. The patient’s cardiovascular examination revealed regular heart rate and rhythm with a 2/6 soft decrescendo murmur in early systole. Abdominal examination revealed normal bowel movements and sounds, no tenderness, and the uterine fundus was not palpable based on the small gestational age. Pelvic examination revealed normal external genitalia with no lesions. Speculum examination showed a pink and moist vaginal wall, mild ectropion on the cervix, and appeared to be undilated. On bimanual examination, the cervix was closed, uterus small and non-tender and there were no adnexal masses. Additionally, there was no usual cervical motion tenderness.

2d) Identify the various diagnostic instruments you would need to use to examine this patient.

Instruments for general assessment will include a thermometer for temperature measuring, a stethoscope for auscultation of heart sounds, and a blood pressure machine to record her BP readings. On pelvic examination, a speculum will be required to help visualize the cervix.

DOMAIN: ASSESSMENT (Medical Diagnosis)

Discuss the pathophysiology of the:

3a) Diagnosis and,

Upon examination, Savannah’s final diagnosis is spontaneous abortion. Spontaneous abortion involves the loss of pregnancy without outside intervention before 20 weeks of gestation (Alves & Rap, 2021). According to Savannah’s ultrasound, her pregnancy was 6 weeks and 4 days old. Abnormal bleeding before 20 weeks gestation is common among women with approximately 20% of the affected women ending up with spontaneous abortion. The pathophysiology of spontaneous abortion is related to hormonal insufficiencies and genetic factors that can alter the uterine environment. Genetic etiologies involving chromosomal defects can be used to explain spontaneous abortion in the early weeks of pregnancy (Alves & Rap, 2021). Insufficient or excessive hormonal levels alongside infections can result in loss of pregnancy before 10 weeks. Because of the different mechanisms involved, spontaneous abortion can either be complete abortion, inevitable abortion, incomplete abortion, threatened abortion, septic abortion, or missed abortion.

3b) Each Differential Diagnosis

Vaginal bleeding during early pregnancy can be caused by different conditions including ectopic pregnancy, molar pregnancy, cervical abnormalities, and idiopathic bleeding in a viable pregnancy (Australian Family Physician (AFP), 2016). The most likely differential diagnosis for Savannah is ectopic pregnancy. This pregnancy commonly happens in the Fallopian tube with a few occurring in the cervix, uterine cornea, ovaries, and abdominal cavity. Causes of ectopic pregnancy can include infections like PID, particularly those caused by Chlamydia trachomatis, tubal lesions, IUCD use, and prior induced abortion (Hendriks et al., 2020). The structure containing the fetus usually ruptures after six weeks leading to bleeding and pelvic pain.

DOMAIN: LABORATORY & DIAGNOSTIC TESTS

Discuss the following:

4a) What labs should be ordered in the case?

The first part of the investigation should involve ordering a complete blood count (CBC). The main utility of the CBC is to detect the hemoglobin level of the patient following abnormal vaginal bleeding (Hendriks et al., 2019). Secondly, CBC can be an important tool to determine if there is an infection that could translate to the diagnosis of septic abortion. Another test that can be useful in this stage is a wet mount preparation for trichomonas and a PCR test for gonorrhea and chlamydia. These infections can be among the common causes of vaginal bleeding. The healthcare provider should also order quantitative beta-human chorionic gonadotropin (beta-hCG) (AFP, 2016). In ectopic and spontaneous abortion, beta-hCG levels will be slightly lower than normal.

4b) Discuss what lab results would be abnormal.

Based on the patient’s presentation, abnormal results may include hematocrit less than 36%, hemoglobin less than 12g/dl, and quantitative beta-hCG less than 1500 IU/mL (Hendriks et al., 2019). Changes in hemoglobin and hematocrit are a result of bleeding while reduced beta-hCG levels can indicate spontaneous abortion.

4c) Discuss what the abnormal lab values indicate.

Abnormal laboratory results on hemoglobin and hematocrit will indicate anemia due to blood loss. Abnormal beta-hCG levels can be used to argue for spontaneous abortion or an ectopic pregnancy that could be the cause of Savannah’s vaginal bleeding (AFP, 2016). However, the beta-hCG levels should be constantly monitored and 1 to 2 serial measurements should be used to draw conclusive results when combined with an ultrasound.

4d) Discuss what diagnostic procedures you might want to order based on the medical diagnosis.

I will want to order an abdominal ultrasound to detect early pregnancy loss or an ectopic pregnancy that could be the cause of vaginal bleeding. Additionally, the ultrasound can provide the level of beta-hCG that can be combined with other results to indicate spontaneous abortion.

 5a) How common is miscarriage?

Miscarriage is the spontaneous loss of pregnancy before 20 weeks of gestation. Commonly observed is vaginal bleeding that occurs in up to 20% of pregnancies, and 50% of these end up with a miscarriage (Alves & Rapp, 2021). However, the incidence of spontaneous abortion may be as high as 30% because most miscarriages occur before pregnancy is realized.

5b) What are the risk factors of miscarriage?

The primary risk factor for miscarriage is advanced maternal age. For instance, only 9% to 17% of women between the age of 20-30 years get a miscarriage while 80% of miscarriages occur between 35-45 years (Feodor Nilsson et al., 2014). Individuals with chronic conditions like diabetes and autoimmune disorders are at risk of miscarriages. Other risk factors include alcohol consumption, smoking, and using other harmful substances.

References

Alves C, Rapp A. (2021). Spontaneous abortion. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK560521/

Australian Family Physician. (2016). Early pregnancy bleeding. https://www.racgp.org.au/afp/2016/may/early-pregnancy-bleeding

Committee on Adolescent Health Care (2017). Committee Opinion No 699: Adolescent pregnancy, contraception, and sexual activity. Obstetrics and Gynecology, 129(5), e142–e149. https://doi.org/10.1097/AOG.0000000000002045

Feodor Nilsson, S., Andersen, P. K., Strandberg-Larsen, K., & Nybo Andersen, A. M. (2014). Risk factors for miscarriage from a prevention perspective: A nationwide follow-up study. BJOG : An International Journal of Obstetrics and Gynaecology, 121(11), 1375–1384. https://doi.org/10.1111/1471-0528.12694

Hendriks, E., MacNaughton, H., & MacKenzie, M. C. (2019). First trimester bleeding: Evaluation and management. American Family Physician, 99(3), 166-174. https://www.aafp.org/afp/2019/0201/p166.html

Hendriks, E., Rosenberg, R., & Prine, L. (2020). Ectopic pregnancy: Diagnosis and management. American Family Physician, 101(10), 599-606. https://www.aafp.org/afp/2020/0515/p599.html

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