NRNP 65521 Case study Assignment Paper

NRNP 65521 Case study Assignment Paper

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Patient Information:

Initials: B.B.     Age: 39yrs     Sex: Female

Subjective Data

Chief Complaint: Positive home pregnancy test.

History of Presenting Illness: Bonita Bubble is a 39-year-old female who presents to the clinic with a positive home pregnancy test as her chief complaint. She reports that her last menstrual period was on 1/15/2023. She reports breast tenderness, fatigue, and nausea, which led her to suspect pregnancy. She reports that these symptoms began around two weeks ago, gradually worsening. She describes the character of her breast tenderness as a dull ache and her nausea as mild to moderate in intensity. She also reports occasional vomiting associated with nausea. Bonita reports that the symptoms are persistent and occur throughout the day. She denies exacerbating or relieving factors for her symptoms. NRNP 65521 Case study Assignment Paper

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Current Medications: Bonita reports taking vitamin supplements for the past six years but not taking any other medications.

Allergies: She reports no known allergies to medications or food.

Past Medical History: Bonita reports no significant medical history. She has had no major illnesses or hospitalizations in the past. Her Pap smear and STD history are negative.

Social and Substance History: Bonita is married and works as a teacher. She reports no history of smoking, alcohol use, or illicit drug use. She denies any recent travel or exposure to sick individuals.

Family History: Bonita reports a family history of hypertension on her father’s side. Otherwise, she reports no significant family history of medical conditions or genetic disorders.

Surgical History: Bonita had a c-section in 2017 for a breech presentation after a failed version. She also had an ectopic pregnancy in 2019, treated with methotrexate.

Reproductive History: Bonita had her first menstrual period at age 12, with cycles coming every 28 days and lasting 5 days. She reports no history of irregular cycles, abnormal bleeding, or pain during menstruation. She had one full-term vaginal delivery with epidural anesthesia and no complications in 2015, one full-term vaginal delivery with epidural anesthesia, one twin’s disappearance in 2016, and one ectopic pregnancy in 2019 NRNP 65521 Case study Assignment Paper.

Review of Systems

General: The patient reports fatigue, a common pregnancy symptom.

HEENT: No reported vision changes, headaches, head traumas, ear pain or discharge, nasal congestion, or sore throat.

Cardiovascular: No reported chest pains or palpitations

Respiratory: Denies difficulty breathing. Reports occasional tiredness.

Breasts: The patient reports breast tenderness, a common pregnancy symptom.

Gastrointestinal: She reports nausea and occasional vomiting, common pregnancy symptoms. NRNP 65521 Case study Assignment Paper

Genitourinary: Reports no dysuria or any other pain reported.

Neurological: Denies confusion or headache.

Psychiatric: Denies depression or anxiety.

Objective Data

General Appearance: Bonita is a 39-year-old female who appears comfortable and in no acute distress. She is alert, oriented, and able to answer questions appropriately.

Vital Signs: B.P 125/88mmHg, HR-80bpm, RR-16bpm, Temp- 98.6°F, SPO2- 98% on room air.

Physical Examination

HEENT: Head: Normocephalic, atraumatic. Eyes: Pupils equal, round, and reactive to light. No scleral icterus, conjunctival injection, or discharge. Ears: Bilateral canals and drums are clear. Nose: No nasal discharge or bleeding. Throat: Oral mucosa is pink, moist, and free of lesions or exudate.

Cardiovascular: Heart sounds S1 and S2 are normal. No murmurs, gallops, or rubs are heard. Jugular venous distention is not noted. Peripheral pulses are equal and symmetric.

Breasts: The breasts are symmetrical, with no discharge, dimpling, or skin changes noted. The breasts are tender to palpation, especially in the upper outer quadrants.

Abdominal Examination: The abdomen is gravid and tense, with a fundal height of approximately 12 weeks. There is no visible abdominal distension or hernias. No abdominal masses, tenderness, or guarding is noted. Bowel sounds are present in all quadrants. NRNP 65521 Case study Assignment Paper

Genitourinary: External genitalia appears normal with no lesions, discharge, or inflammation noted. Vaginal walls are pink, moist, and without discharge.

Diagnostic Tests

Bonita will require comprehensive laboratory tests, including a urine pregnancy test to confirm pregnancy and a complete antenatal profile. This will include having a complete blood count to detect anemia common in pregnancy, blood typing and Rh factor test for fetal Rh compatibility, rubella titter for immunity to Rubella, and HIV and Syphilis test, as they can be transmitted to the fetus. She will also need a urinalysis test to determine the presence of urinary tract infections and normal kidney function. Fetal ultrasound will also be required to assess the fetal anatomy and growth.

Assessment

Differential Diagnosis

Normal Pregnancy: Bonita’s symptoms, including breast tenderness, fatigue, and nausea, are typical of early pregnancy symptoms. She has a positive pregnancy test, and the abdominal examination indicates a 12-week gestation. Therefore, Bonita is likely pregnant.

Ectopic Pregnancy: Bonita has a history of ectopic pregnancy, which is associated with symptoms similar to normal pregnancy. An ectopic pregnancy is a pregnancy complication in which the fertilized egg implants outside the uterus, typically in one of the fallopian tubes (Mummert & Gnugnoli, 2019)NRNP 65521 Case study Assignment Paper. This is a dangerous condition because the growing embryo can cause the fallopian tube to rupture, leading to severe bleeding and potentially life-threatening complications for the mother.

Gestational Trophoblastic Disease: Gestational Trophoblastic Disease (GTD) is a rare pregnancy-related disease resulting from abnormal placenta growth (Soper, 2021). GTD can cause abnormal uterine bleeding and other symptoms similar to pregnancy, such as breast tenderness and nausea.

Most Important Diagnosis: The most important diagnosis, in this case, is normal pregnancy, which is the most common cause of Bonita’s symptoms. It is characterized by elevated beta HCG, which is usually detected in the home pregnancy test (Betz & Fane, 2019). However, given her history of ectopic pregnancy, it must be excluded as it can be life-threatening.

Plan

Bonita should undergo a urine pregnancy test to confirm pregnancy. If positive, she should have comprehensive laboratory tests, including a complete blood count to detect her hemoglobin levels for potential pregnancy-associated anemia and other infections; blood typing and Rh factor test will help identify her blood type in case transfusion is needed, and Rh factor will determine maternal-fetal compatibility, rubella titer, and HIV and Syphilis test will also be needed as these infections may interfere with pregnancy. A urinalysis test should also be performed. Fetal ultrasound should be done to assess the fetal anatomy and growth and to rule out ectopic pregnancy (Ulrich & Dewald, 2020)NRNP 65521 Case study Assignment Paper. She should also receive folic acid supplementation to reduce the risk of neural tube defects in the developing fetus. If an ectopic pregnancy is suspected, transvaginal ultrasound and serum beta-HCG levels should be monitored, and immediate treatment with methotrexate should be initiated.

Reflection

Based on the provided patient information, the preceptor’s treatment of the patient seems appropriate. The patient presented with a positive home pregnancy test, breast tenderness, fatigue, and nausea. Her abdominal examination indicated a 12-week gestation, and she had a history of ectopic pregnancy. Therefore, the preceptor’s decision to order comprehensive laboratory tests, including a urine pregnancy test to confirm pregnancy, a complete antenatal profile, and fetal ultrasound, was appropriate.

This case taught me that a comprehensive evaluation is essential for patients with positive home pregnancy tests. This includes laboratory tests and ultrasounds to confirm the pregnancy and ensure the fetus grows appropriately. Additionally, it is important to consider the patient’s history of previous pregnancies and pregnancy complications, such as ectopic pregnancy, when evaluating and managing their current pregnancy.

If I were in the preceptor’s position, I would consider the patient’s history of ectopic pregnancy and monitor her closely for any signs or symptoms of another ectopic pregnancy. I will also discuss the signs and symptoms of ectopic pregnancy, the risk factors, and the need for immediate medical attention if she experiences any of these symptoms.

References

Betz, D., & Fane, K. (2019, January 16). Human chorionic gonadotropin (HCG). Nih.gov; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK532950/

Mummert, T., & Gnugnoli, D. M. (2019, March 10). Ectopic pregnancy. Nih.gov; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK539860/

Soper, J. T. (2021). Gestational trophoblastic disease. Obstetrics & Gynecology, 137(2), 355–370. https://doi.org/10.1097/aog.0000000000004240

Ulrich, C. C., & Dewald, O. (2020). Pregnancy ultrasound evaluation. PubMed; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK557572/ NRNP 65521 Case study Assignment Paper

Episodic/Focused SOAP Note Template

 Patient Information:

Initials, Age, Sex, Race

S.

CC (chief complaint): This is a brief statement identifying why the patient is here in the patient’s own words, for instance, “headache,” not “bad headache for 3 days.”

HPI: This is the symptom analysis section of your note. Thorough documentation in this section is essential for patient care, coding, and billing analysis. Paint a picture of what is wrong with the patient. Use LOCATES Mnemonic to complete your HPI. You need to start every HPI with age, race, and gender (e.g., 34-year-old African American female). You must include the seven attributes of each principal symptom in paragraph form, not a list. If the CC was “headache,” the LOCATES for the HPI might look like the following example:

Location: head

Onset: 3 days ago

Character: pounding, pressure around the eyes and temples

Associated signs and symptoms: nausea, vomiting, photophobia, phonophobia

Timing: after being on the computer all day at work

Exacerbating/relieving factors: light bothers eyes, Naproxen makes it tolerable but not completely better

Severity: 7/10 pain scale

Current Medications: Include dosage, frequency, length of time used, and reason for use. Also include over-the-counter (OTC) or homeopathic products.

Allergies: Include medication, food, and environmental allergies separately. Provide a description of what the allergy is (e.g., angioedema, anaphylaxis). This will help determine a true reaction versus intolerance. NRNP 65521 Case study Assignment Paper

PMHx: Include immunization status (note date of last tetanus for all adults), past major illnesses, and surgeries. Depending on the CC, more info is sometimes needed.

Soc & Substance Hx: Include occupation and major hobbies, family status, vaping, tobacco and alcohol use (previous and current use, how many times a day, how many years), and any other pertinent data. Always add some health promotion questions here, such as whether they use seat belts all the time or whether they have working smoke detectors in the house, the condition of the living environment, text/cell phone use while driving, and support systems available.

Fam Hx: Illnesses with possible genetic predisposition, contagious illnesses, or chronic illnesses. The reason for death of any deceased first-degree relatives should be included. Include parents, grandparents, siblings, and children. Include grandchildren if pertinent.

Surgical Hx: Prior surgical procedures.

Mental Hx: Diagnosis and treatment. Current concerns: (Anxiety and/or depression). History of self-harm practices and/or suicidal or homicidal ideation.

Violence Hx: Concern or issues about safety (personal, home, community, sexual—current and historical).

Reproductive Hx: Menstrual history (date of last menstrual period [LMP]), pregnant (gravida and Parity), nursing/lactating (yes or no), contraceptive use (method used), types of intercourse (oral, anal, vaginal, other), gender sexual preference, and any sexual concerns.

ROS: This covers all body systems that may help you include or rule out a differential diagnosis. You should list each system as follows: General: Head: EENT: and so forth. You should list these in bullet format and document the systems in order from head to toe.

Example of Complete ROS:

GENERAL: No weight loss, fever, chills, weakness, or fatigue.

HEENT: Eyes: No visual loss, blurred vision, double vision, or yellow sclerae. Ears, Nose, Throat: No hearing loss, sneezing, congestion, runny nose, or sore throat.

SKIN: No rash or itching. NRNP 65521 Case study Assignment Paper

CARDIOVASCULAR: No chest pain, chest pressure, or chest discomfort. No palpitations or edema.

RESPIRATORY: No shortness of breath, cough, or sputum.

GASTROINTESTINAL: No anorexia, nausea, vomiting, or diarrhea. No abdominal pain or blood.

NEUROLOGICAL: No headache, dizziness, syncope, paralysis, ataxia, numbness, or tingling in the extremities. No change in bowel or bladder control.

MUSCULOSKELETAL: No muscle pain, back pain, joint pain, or stiffness.

HEMATOLOGIC: No anemia, bleeding, or bruising.

LYMPHATICS: No enlarged nodes. No history of splenectomy.

PSYCHIATRIC: No history of depression or anxiety.

ENDOCRINOLOGIC: No reports of sweating or cold or heat intolerance. No polyuria or polydipsia.

GENITOURINARY/REPRODUCTIVE: Burning on urination. Pregnancy. LMP: MM/DD/YYYY. Breast-lumps, pain, discharge? No reports of vaginal discharge, pain?. sexually active?

ALLERGIES: No history of asthma, hives, eczema, or rhinitis.

O.

Physical exam: From head to toe, include what you see, hear, and feel when conducting your physical exam. You only need to examine the systems that are pertinent to the CC, HPI, and history. Do not use “WNL” or “normal.” You must describe what you see. Always document in head-to-toe format (i.e., General: Head: EENT:).

Diagnostic results: Include any labs, x-rays, or other diagnostics that are needed to develop the differential diagnoses (support with evidenced and guidelines)NRNP 65521 Case study Assignment Paper.

A.

Primay and Differential Diagnoses (list a minimum of 3 differential diagnoses). Your primary or presumptive diagnosis should be at the top of the list. For each diagnosis, provide supportive documentation with evidence-based guidelines.

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Includes documentation of diagnostic studies that will be obtained, referrals to other health care providers, therapeutic interventions, education, disposition of the patient, and any planned follow-up visits. Each diagnosis or condition documented in the assessment should be addressed in the plan. The details of the plan should follow an orderly manner. Also included in this section is the reflection. The student should reflect on this case and discuss whether or not they agree with their preceptor’s treatment of the patient and why or why not. What did they learn from this case? What would they do differently?

Also include in your reflection a discussion related to health promotion and disease prevention, taking into consideration patient factors (e.g., age, ethnic group), PMH, and other risk factors (e.g., socioeconomic, cultural background).

References

You are required to include at least three evidence-based, peer-reviewed journal articles or evidenced-based guidelines that relate to this case to support your diagnostics and differentials diagnoses. Be sure to use correct APA 7th edition formatting NRNP 65521 Case study Assignment Paper