NU576 Unit 7 Journal

NU576 Unit 7 Journal

Student Name

NU576 NP II – Primary Care of Women’s Health

Prof. Name:

Date

NU576 Unit 7 Journal

A 35-year-old pregnant patient presenting at 20 weeks’ gestation is establishing prenatal care after relocating from Ohio. Her primary concerns are pregnancy-related lower back pain and the need for continued prenatal monitoring. The clinical evaluation is consistent with a normal second-trimester pregnancy, with additional attention needed for her history of depression, previous pregnancy losses, alcohol use during pregnancy, and appropriate prenatal screening.

Patient Information

Patient Name: Lara Taylor
Encounter Number: 5466525
Date of Visit: October 10, 2023
Age: 35 years
Sex: Female

Subjective Assessment

Chief Complaint

The patient states, “I’m here to establish prenatal care. I just moved here from Ohio.”

History of Present Illness

The patient is a 35-year-old female who presents at 20 weeks pregnant for establishment of prenatal care following a recent move from Ohio. She reports no major pregnancy complaints except lower back pain, which she attributes to her growing abdomen.

The back pain is described as a “tugging” sensation. She reports that symptoms worsen after standing for extended periods and improve with rest. This is her third pregnancy. Her obstetric history includes one previous abortion and one miscarriage.

She is currently taking over-the-counter prenatal vitamins. She previously used Lexapro for depression but discontinued the medication several years ago.

Allergies and Medication Intolerances

• Allergy: Latex (causes rash)

• Medication intolerances: None reported

Past Medical and Surgical History

Medical History

The patient reports two previous episodes of depression, both related to prior pregnancies. She denies chronic illnesses or major traumatic injuries.

Surgical History

• Dilation and curettage (D&C) performed 5 years ago

Family History

The patient reports the following family history:

• Father died at age 60 from a myocardial infarction.

• Mother is living and has had diabetes for 10 years.

• Brother has no known health concerns.

Social History

The patient completed university education and earned a teaching certificate. She currently works as a substitute teacher.

She recently married three months ago and currently lives with her husband, who is unemployed following their recent relocation.

Relevant social factors include:

• Former tobacco use: Previously smoked one pack of cigarettes daily but stopped after discovering pregnancy.

• Alcohol use: Reports drinking one glass of wine nightly.

• Drug history: Denies current drug use but reports previous marijuana use and consumption of hemp gummies.

Review of Systems

General

The patient reports:

• Weight increase from 155 pounds to 167 pounds since becoming pregnant

• Increased fatigue associated with pregnancy

Cardiovascular

Denies:

• Chest pain

• Palpitations

Respiratory

Denies:

• Cough

• Congestion

• Shortness of breath

Eyes

Denies:

• Blurry vision

• Vision changes

She does not wear corrective lenses.

Gastrointestinal

Denies:

• Abdominal pain

• Nausea

• Vomiting

• Diarrhea

Reports constipation since becoming pregnant.

Genitourinary and Gynecological

Denies:

• Hearing-related concerns

• Urinary pain or burning

Reports:

• Increased urinary frequency since pregnancy

• Current sexual activity with her husband

Musculoskeletal

Reports lower back pain described as a “tugging” sensation related to pregnancy changes.

Breast

Denies:

• Breast pain

• Discharge

• Masses

Reports increased breast size during pregnancy.

Neurological

Denies:

• Weakness

• Dizziness

• Seizures

Hematologic, Lymphatic, and Endocrine

Denies:

• Excessive hunger

• Excessive thirst

• History of blood transfusion

The patient reports a previous HIV test during her first prenatal visit with her former obstetric provider.

Psychiatric

The patient has a history of two depressive episodes associated with previous pregnancies. She previously took Lexapro but stopped several years ago.

During the interview, she appears to avoid eye contact and looks downward when discussing her husband, which may require further assessment of emotional well-being and social support.

Objective Assessment

Vital Signs and Measurements

• Weight: 167 pounds

• BMI: 30.5

• Height: 5 feet 2 inches

• Temperature: 98.0°F

• Blood pressure: 132/64 mmHg

• Pulse: 75 beats/minute

• Respiratory rate: 20 breaths/minute

Physical Examination

General Appearance

The patient appears healthy and is cooperative during the examination. She answers questions appropriately with no obvious abnormalities.

Skin

Skin is dry and intact. No bruising, lesions, or discoloration noted.

HEENT Examination

• Head: Normocephalic and nontender

• Eyes: Pupils equal, round, reactive to light and accommodation (PERRLA)

• Ears: Symmetrical and patent bilaterally

• Nose: Nares patent

• Mouth: Teeth intact without dental caries

Cardiovascular Examination

• Regular rate and rhythm

• Normal S1 and S2 heart sounds

• No murmurs or extra heart sounds

• No peripheral edema

Respiratory Examination

• Chest expansion symmetrical

• Breath sounds clear bilaterally

• Respirations even and unlabored

Gastrointestinal Examination

• Pregnant abdomen noted

• Bowel sounds present in all quadrants

• No abdominal tenderness

Breast Examination

• Breasts nontender

• No masses, skin discoloration, or discharge noted

Genitourinary Examination

• Bladder nondistended and nontender

• Normal rectal tone

• Pap examination completed using speculum

Findings include:

• Normal vulva without lesions or masses

• Normal vaginal appearance

• Cervix without discharge or lesions

• Anteverted, nontender uterus

• No internal or external hemorrhoids

Musculoskeletal Examination

• Full range of motion in all extremities

• No stiffness or significant pain noted

Neurological Examination

• Clear speech

• Steady gait

• Straight posture

Psychiatric Examination

The patient is alert and oriented to person, place, and time. Appearance, speech, and behavior are appropriate. Additional evaluation is recommended due to her history of depression and observed discomfort when discussing her spouse.

Laboratory and Diagnostic Testing

Recommended prenatal laboratory testing includes:

• Complete blood count (CBC) to evaluate for anemia

• Blood type and Rh factor testing to assess incompatibility risk

• Hepatitis B, syphilis, and HIV screening to identify infections that may affect pregnancy outcomes

• Glucose screening to evaluate for gestational diabetes

• Pregnancy confirmation testing when clinically indicated

• Ultrasound monitoring to assess fetal growth and development

Assessment

Primary Diagnosis: Second Trimester Pregnancy (13–26 Weeks Gestation)

The patient is currently in the second trimester of pregnancy. This stage is commonly associated with reduced morning sickness, increased appetite, uterine growth, breast enlargement, weight gain, urinary frequency, and possible constipation.

Her pregnancy-related lower back pain is likely associated with musculoskeletal changes, increased abdominal weight, and postural adjustments during pregnancy.

Differential Diagnoses

Miscarriage

Miscarriage is the loss of a pregnancy before approximately 20 weeks of gestation. Symptoms may include:

• Vaginal bleeding

• Abdominal cramping or pain

• Passage of blood clots or pregnancy tissue

Although the patient has a history of miscarriage, she currently denies symptoms suggestive of pregnancy loss.

Molar Pregnancy

A molar pregnancy occurs when abnormal tissue develops from a fertilized egg instead of a normally developing fetus. Patients may experience pregnancy symptoms despite abnormal placental development. Treatment typically requires removal of the abnormal tissue.

Plan of Care

Medications

Medication recommendations should be individualized based on symptoms and pregnancy safety. Potential options may include:

• Acetaminophen (Tylenol) for pregnancy-related pain when appropriate

• Docusate sodium (Colace) for constipation management

• Famotidine (Pepcid) for pregnancy-related reflux symptoms if needed

• Other medications such as Benadryl or Imodium only when clinically appropriate and after provider evaluation

Non-Pharmacological Recommendations

The patient should be encouraged to:

• Remain physically active as tolerated

• Avoid prolonged standing when possible

• Use rest periods to reduce back discomfort

• Practice proper posture and body mechanics

• Consider pregnancy-safe stretching exercises

Patient Education

Important education topics include:

• Avoiding alcohol during pregnancy due to potential fetal risks

• Maintaining regular prenatal appointments

• Recognizing warning signs such as vaginal bleeding, severe abdominal pain, decreased fetal movement later in pregnancy, severe headaches, or vision changes

• Continuing prenatal vitamins

Mental Health Screening

Due to her history of depression associated with previous pregnancies, the patient should receive routine depression screening and monitoring for perinatal mood disorders.

Health Promotion

Recommended preventive care includes:

• Routine prenatal follow-up

• Nutrition counseling

• Gestational diabetes screening

• Infection screening

• Emotional health assessment

Referrals

Recommended referral:

• Obstetrician/gynecologist (OB/GYN) for continued prenatal management

Follow-Up

The patient should return for follow-up in approximately four weeks or sooner if concerning symptoms develop.

References

Allo Health. (2023, July 15). Differential diagnosis of pregnancy: A comprehensive guide. Allo Health. https://www.allohealth.care/healthfeed/pregnancy/differential-diagnosis-of-pregnancy

Cleveland Clinic. (2018, January). Medicine guidelines during pregnancy. Cleveland Clinic. https://my.clevelandclinic.org/health/drugs/4396-medicine-guidelines-during-pregnancy

NU576 Unit 7 Journal

Johns Hopkins Medicine. (2021, August 8). The second trimester. Johns Hopkins Medicine. https://www.hopkinsmedicine.org/health/wellness-and-prevention/the-second-trimester

Nguyen, T. (2022, July). Prenatal tests: Second trimester. KidsHealth. https://kidshealth.org/en/parents/tests-second-trimester.html