Respond to the post and explain how you might think differently about the types of tests or treatment options your colleagues suggested and why. Use your learning resources and/or evidence from the literature to support your position.

Topic: To prepare:

• By Day 1 of this week, you will be assigned to a specific scenario for this Discussion. Please see the “Course Announcements” section of the classroom for your assignment from your Instructor.

• Review the Learning Resources for this week as well as Weeks 5 and 6 and specifically review the clinical guideline resources specific to your assigned case study.

• Use the Focused SOAP Note Template found in the Learning Resources to support Discussion. Based on the case study scenario provided, complete a SOAP note and critically analyze this and focus your attention on the diagnostic tests. 

By Day 3

Based on your assigned case study, post a Focused SOAP NOTE with the following:

• Differential diagnosis (dx) with a minimum of 3 possible conditions or diseases.

• Define what you believe is the most important diagnosis. Be sure to include the first priority in conducting your assessment.

• Explain which diagnostic tests and treatment options you would recommend for your patient and explain your reasoning.

Student’s post :

Patient Information

P.H., 29-years-old, Female, Hispanic

Vital Signs: Temp: 98.1, Pulse: 75, Resp: 20, B/P: 112/68, O2: 99%, Weight: 176 lbs

S.

CC (chief complaint): Positive Pregnancy Test

HPI: P.H. is a 29-year-old female who presents with reports of a positive home pregnancy test she took one week ago. She reports breast tenderness, fatigue, and nausea, which is consistent with her past pregnancy symptoms. Her last menstrual period was 12/25/17 and symptoms were consistent with her usual pattern.

Current Medications: Vitamin gummy once a day

Allergies: No known allergies

PMHx: Unremarkable

All vaccinations up to date

Influenza vaccine 10/2017

Tetanus date: Patient reports last shot received during childhood

Soc & Substance Hx: P.H. currently lives in a three-bedroom townhouse with her fiancé and children. She and her fiancé have lived together for the past 5 years. She works as a supervisor at Amazon and her fiancé works in an accounting office. Her support system includes her fiancé’s parents that live in the same complex and her parents and younger sister who live about a mile from her. She consumes a vegetarian diet (change occurred since her last pregnancy). She denies smoking, alcohol, or recreational drug use.

Fam Hx:

Mother: Alive with DM and HTN

Father: Alive with BPH

Sister: Alive with no medical history

Brother: Alive with no medical history

Maternal grandmother: Alive with a history of DM and HTN

Maternal grandfather: Alive with Prostate cancer

Paternal grandmother: Deceased from Ovarian cancer at 95 years old

Paternal grandfather: Alive living with HTN

Surgical Hx: None

Mental Hx: None Current concerns: None

Violence Hx: Patient denies any safety concerns

Reproductive Hx: P.H. began her meses at the age of 12.  Her last menstrual period was 12/25/2017. She doesn’t utilize any contraceptives currently. She participates in vaginal and oral intercourse. She is not currently lactating. Her reproductive history is as follows G5T2P1A2L3.

ROS:

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

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.

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

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

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

GENITOURINARY: Burning on urination. Last Pregnancy 2017. LMP: 12/25/2017.

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.

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

REPRODUCTIVE: Breast tenderness; Not pregnant. She gave birth 7 months ago. No reports of vaginal discharge. She is currently sexually active.

O.

Physical exam:

GENERAL: Patient appears in good spirits and well-groomed.

CARDIOVASCULAR: S1 and S2 auscultated. No murmurs were noted.

RESPIRATORY: Lung sounds clear in all fields

GASTROINTESTINAL: Bowel sounds auscultated in all quadrants. Abdomen is soft and non-tender.

GENITOURINARY: Patient is not currently on her menses.

REPRODUCTIVE: Breast uniformly nodular and tender to medium palpation. ; Not pregnant. She gave birth 7 months ago. No reports of vaginal discharge. She is currently sexually active.

Diagnostic results:

• Urine Pregnancy Test- Positive

A.

• Pregnancy- The positive pregnancy test confirmed in the office makes this the most likely diagnosis. An ultrasound would be needed to further confirm the gestational age and the viability of the embryo.

• Ectopic Pregnancy- This could be a likely diagnosis because it could also cause a positive pregnancy test and symptoms associated with pregnancy due to the rise in hormones (Ucisik‑Keser, Matta, Fabrega, Chandrasekhar, & Chua, 2021). The challenge with an ectopic pregnancy is the implantation location being anywhere other than the endometrium (Ucisik‑Keser, Matta, Fabrega, Chandrasekhar, & Chua, 2021).

• Ovarian Cancer- metastatic mucinous ovarian carcinoma is one type of ovarian cancer that can increase the beta HCG levels to cause a positive pregnancy test (Goldstein, Pandey, Fleming, & Westin, 2016). An ultrasound would identify the presence of a mass that would warrant further evaluation.

P.

1.            Transvaginal ultrasound

2.            Labs

a.    Beta HCG level- this would assist in determining if the level of hormone matches the gestational age obtained by the ultrasound.

b.    CBC- Obtained for baseline laboratory values

c.    CMP- Obtained for baseline laboratory values

d.    Hemoglobin A1C- Her history of gestational diabetes makes it important to see how her glucose management has been.

3.            Start taking a prenatal vitamin of your choice

4.            Educate on participating in physical activity and maintaining a healthy diet to decrease the potential for pregnancy-related complications (Rockliffe, Peters, Heazell, & Smith, 2021).

5.            Educate on wearing a seatbelt and no texting while driving

6.            Follow-up in 1 week after labs are drawn.

 

Reflection

         The fact that the patient has a history of being pregnant five times one would lean on her experience and assume she would know the difference between her symptoms and her believing she is pregnant. The presence if cancer that can produce elevated levels of beta HCG was a new point, I have learned in creating this post. This causes there to be a need to ensure confirmatory exams are completed to ensure we do not miss any of the other possible diagnoses.

References

 

Goldstein, J., Pandey, P., Fleming, N., & Westin, S. (2016). A non-pregnant woman with elevated beta-HCG: A case of para-neoplastic syndrome in ovarian cancer. Gynecologic Oncology Reports, 49-52.

Rockliffe, L., Peters, S., Heazell, A. E., & Smith, D. M. (2021). Factors influencing health behaviour change during pregnancy: a systematic review and meta-synthesis. Health Psychology Review, 613-632.

Ucisik‑Keser, F., Matta, E. J., Fabrega, M. G., Chandrasekhar, C., & Chua, S. S. (2021). The many faces of ectopic pregnancies: demystifying the common and less common entities. Abdominal Radiology, 1104-1114.

 

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