WWW.DISSERTATION.XLIBX.INFO
FREE ELECTRONIC LIBRARY - Dissertations, online materials
 
<< HOME
CONTACTS



Pages:   || 2 |

«SAMPLE WORK-UP ID: Patient is 21 yo G2P1001 At 32 2/7 GA determined by serial U/S Admitted for vaginal bleeding. HPI: The patient first noticed ...»

-- [ Page 1 ] --

SAMPLE WORK-UP

ID: Patient is 21 yo G2P1001 At 32 2/7 GA determined by serial U/S Admitted for

vaginal bleeding.

HPI: The patient first noticed vaginal bleeding this morning when she work up at 6:25 am

to use the restroom. She noticed bleeding in her clothing and blood clots in the toilet

bowl. She was transported by ambulance to the hospital from the prison she has been for

4 months. She reports bleeding 1 cup (~250cc) total this morning. In addition, she has a positive h/o placenta previa with her current pregnancy determined by U/S. She denies any similar episodes in the past with either pregnancy, as well as having pain, cramps, nausea, fever, chills or recent trauma.

Prenatal Care: Dr. _______ at Farm Worker’s Clinic

Pregnancy complicated by:

1) Partial placenta previa

PNL:

- Blood type: O+

- Rubella Ab titer: Immune

- VDRL: NR

- Hep B: NR

- Cervical gonorrhea & Chlamydia culture:

- Pap smear: normal

- PPD: not done

- Sickle prep: not done

- HIV test: NR

- Glucose test: Denies having it done

- Group B strep: not done

- Herpes: Denies

- Seizures: Denies

- Hep C: NR

PMH:

Gyn PMH:

- Menarches: 15 yoa

- Menses: Regular 28 day cycles with 4 day duration menses; heavy flow first two days and becomes gradually lighter toward end of menses

- Contraception hx: Denies use of barrier or hormonal methods.

Ob PMH:

- 2002: C-section 2ary to non-reassuring fetal heart tracings, boy, wgt: 7 lbs. Given for adoption.

PSH:

- c-section: 2002, no complication

- Indirect hernia: At 5 yoa Current medications: Prenatal multivitamins Allergies: Penicillin

Habits/risk factors:

- EtOH: Denies use

- Tobacco use: Denies use

- Recreational drugs/others: Marijuana, every other day; has not smoked since incarceration 4 months ago.

SH: The patient grew up in California with her mother and she has no siblings. She has an 11th grade education. She came to visit a friend in Yakima, WA, one year ago and has stayed in Yakima ever since. She denies having a job and states to meet her financial needs by having friends and her mother help her with finances.

FMH: Unremarkable

PE:

- VS: BP: 116/73 (sitting), P: 89, RR: 18, T: 36.7

- Gen: Well-nourished, slender body habitus, A & O, in NAD

- Skin: Pink, cool and dry

- Pulmonary: LCAB

- Back: No CVA or spinal tenderness to percussion

- CV: RRR, no murmurs heard.

- Abd: Borborgymi present. Distended, no tenderness to palpation

- Fundus: 32 cm, firm

- Extremities: No edema

- NST: baseline FHR of 137, reactive with accelerations and frequent variability

- U/S: Reveals placenta with partial coverage of cervical internal os.

Assessment:

1) Hemodynamically stable 21 yo G2P1001 with vaginal bleeding and U/S consistent with placenta previa.

Differential Diagnosis:

1) Obstetric causes:

a. Placental: Placental previa, placental abruption, circumvallata placenta, placenta accreta, placenta increta, placenta percreta b. Maternal: Uterine rupture, clotting disorders c. Fetal: Fetal vessel rupture

2) Non-obstetric causes:

a. Cervical: Severe cervicitis, polyps, benign/malignant neoplasms b. Vaginal: Lacerations, varices, benign/malignant neoplasms c. Other: Hemorrhoids, bleeding disorder, abd/pelvic trauma

Discussion:

There are multiple causes of vaginal bleeding on the third trimester of pregnancy.

Placental causes of vaginal bleeding include placental abruption, which is seen in 30% of 3rd trimester hemorrhages. IN placental abruption, there is a premature separation of normally implanted placenta from uterine wall resulting in hemorrhage between uterine wall and placenta. It can present with painful bleeding, but no always, in conjunction with abdominal paint, uterine tenderness and uterine contractions. Risk factors for placenta abrupta are hypertension, history of abruption, trauma, AMA, cigarette/cocaine use, rapid decompression of overextended uterus. When placental abruption is considered as a possible cause of vaginal bleeding, it is necessary to obtain a CDC, coagulation panel, fibrinogen levels, FDP, Apt test, ultrasound, and sterile speculum exam. In addition, blood type and cross match should be ready in case of emergency.

Placenta previa occurs in 20% of 3rd trimester hemorrhage and should also be part of the differential diagnosis. Placenta previa occurs when there is abnormal implantation of placenta over internal cervical os, which an be complete, partial or marginal. The classic presentation of placenta previa involves painless vaginal bleeding (in 70% of cases), and it is more common in the third trimester. Risk factors for placenta previa include prior placenta previa, uterine, scars, multiple gestations, multiparity, prior cesarean, cigarette smoking, and weakly with AMA. The average gestational age at the time of first bleeding episode is 29-30 wks. Although bleeding may be substantial, is usually resolves spontaneously. The bleeding is a result of separation of part of the placenta from the lower uterine segment and cervix, perhaps in response to small UC’s. The basic management of patients with placenta previa includes hospitalization with hemodynamic stabilization, followed by expectant management until fetal maturity has occurred or delivery, preferably by c-section, if pregnancy is equal to or over 37 wks gestations.





Maternal blood loss should be replaced to hematocrit within normal limits in pregnancy Rh immune globulin should be given when isoimmunization is a concern (i.e. Rh neg patients).

When encountering a patient with placenta previa the possibility of placenta accreta and its variants, placenta increta and placenta percreta, should be considered. Placenta accreta refers to placental attachment directly to the myometrium. In placenta increta, the placenta invades the myometrium. Placenta percreta is a more server form, with penetration of the thickness of the myometrium and beyond. Invasion can extend to the bladder. Risk factors associated with placenta accreta are prior c-section and any other uterine surgeries. A presentation of placenta previa plus previous h/o other uterine surgery carries a 4% incidence of placenta accreta. In addition, a history of c-section plus a presentation of placenta previa in current pregnancy is associated with a 10-35% incidence of placenta accreta. Management of placenta accreta depends of whether uterine preservation is an option or strongly desired. Two thirds of patient with a placenta accreta require cesarean hysterectomy. Other surgical interventions to stop blood loss that have been successful are packing lower segment with subsequent vaginal removal of packs in 24 hours and interrupted circular suture of lower uterine segmentation on serosal surface of uterus. If complete placenta accreta is suspected or confirmed management should include having at least 4 units of matched blood on hand, an anesthesiologist present in room, and surgical instruments sterile and ready for delivery. Hysterectomy is associated with the most survival and least morbidity of the treatments available for placenta accreta. There are three other options that preserve the uterus. The first option involves oversewing uttering defects after placental removal in conjunction with oxytocics and antibiotics. The second option is localized resection of uterus and repair.

The third option entails curettage of uterine cavity. A fourth option is to leave the placenta in situ and removed at a later date, around two months. ON occasion, ballooning of the abdominal aorta is used to minimize blood loss.

Abruptio placentae constitutes a premature separation of the normally implanted placenta from the uterine wall. Although abruption placentae share some of the clinical feature of placenta previa, particularly vaginal bleeding, it is often accompanied with abdominal discomfort and painful uterine contractions, which distinguishes it. Erica’s U/S assessment showed no hemorrhage into the decidua balsalis or other signs of abrupto placentae, as well as no clinical presentation of pain or UC’s.

Rupture of a fetal vessel is also a possibility in vaginal bleeding during pregnancy. Signs that support fetal vessel rupture are fetal tachycardia followed by bradycardia and by examination of the lbood passed vaginally with an APT test (hemoglobin alkaline denaturation test).

The approach to a patient with vaginal bleeding in the second half of pregnancy should being by promptly assessing fetal and maternal status. Ultrasonography, cervical examination, and lab work including Kleihauer-Betke (KB) test can bring new clues as to the etiology of the patient’s vaginal bleeding. Adjunct tests include color Doppler to assess for placenta accreta and APT of vaginal blood.

Based on the patient’s negative history for 2nd trimester vaginal bleeding, premature labor, PPROM, closed cervix and lack of labor contractions, it is unlikely that her vaginal bleeding is a sign of premature labor. The patient has a positive history of placenta previa with this pregnancy in addition to a previous c-section which leads to suspect vaginal bleeding caused by partial placenta previa. U/S/ revealed no signs of placenta accreta, increta, or percreta. The best medical approach for her pregnancy’s gestational age is expectant management in the hospital with bed rest, with details discussed below.

Plan:

1) Hospitalize patient and initiate bed rest for at least 5 days for evaluation

2) Assess maternal and fetal status by monitoring maternal vital signs and NST for fetal heart function daily for hospital stay duration.

3) Ultrasound uterus and evaluate fetal growth, movement, and heart functioning, placental location and implantation status.

References:

Placenta Accreta. UpTpoDate. Sept 2005 Beckmann, C. Obstetrics and Gynocology. 4th Ed., p. 286-290 and P. 178.

–  –  –

Patient:

ID/CC: 21 y.o. Go presenting for annual exam

HPI:

1. Health maintenance/well woman exam: She states that she has not received medical care since the age of 17, and I s establishing care at the HMC Women’s Clinic. She is recently engaged and has never had a pap smear or testing for STDs/HIV and would also like to have this done today. She has questions about hormonal contraception and would like to discuss “the patch” today.

2. “Depression”: Patients is concern that she may be depressed. She states she was in her normal state of health until one year ago, when she lost her job, and since then has been feeling down, more tearful than usual, with feelings of worthlessness at least every other day. She has problems concentrating and with motivation. She states that she has not looked for a new job because “I know I will not get one because I’m not good enough”.

She states that she has been eating less than usual; her appetite is decreased, and is more sensitive to criticism. She has lost 10 pounds in the last year, but is very upset if she gains weight. She denies a history of anorexia or bulimia, and denies inducing vomiting after eating, eating large quantities at once, or intentionally restricting her diet. Her fiancé has noticed that she is less interested in things that she used to enjoy, although she denies anhedonia. She states that she cries more easily and is tearful quite often, although she is not sure why she is crying.

She states that she sleeps eight to nine hours a night, has no difficulties falling asleep or waking up during the night, but finds it very difficult to wake up in the morning. She also states that she feels tired during the day and finds herself taking frequent naps in the afternoon.

Patient states that she has thought about suicide and has thoughts of “why is life worthy living?”, but denies planning for suicide, suicide attempts, or self-harming behaviors.

3. H/O of anemia. She was diagnosed with anemia at age 17 and is currently taking multiple vitamins with iron. She states that she feels tired and has no energy.

–  –  –

PGynHx: Menarche at 12. Regular periods q month, lasing 3 days.

Coitarche at 20, with one lifetime sexual partner, her fiancé. She believes that she is also his first and only sexual partner, but would like to be tested for STDs. Patient is using condoms as her only method of birth control, and has never taken oral contraceptives or used another form of birth control. She is interested in the “patch”.

She has no history of STDs, or pap smears, vaginal discharge, itching, odor, or abnormal bleeding, although she states she has pain during intercourse with initial penetration and deep penetration.

FH: Maternal grandmother had coronary artery disease. She has no family history of diabetes or cancer. She has no known family history of depression or anxiety.

SH: Patient is currently unemployed. She lives in the Seattle area with her roommate. She is recently engaged, and states that she feels safe at home and with her fiancé. She describes him as loving and attentive and on questioning, denies that he has been emotionally, sexually, or physically abusive. She denies alcohol, tobacco, or drug use.

ROS:

CV: Negative Resp: No history of asthma, history of TB at age 10, treated.

GI: Negative for diarrhea, constipation, hematochezia, or melena.

Musculoskeletal: Negative. No arthritis or muscle pains.

Endocrine: No history of diabetes, hyper – or hypo- thyroidism.

Heme: Negative for h/o blood clots or prolonged bleeding.

Neuro: Negative for seizures or strokes. Headaches once a month.

Psych: See HPI Renal: Negative.

Female Reproductive: See HPI/Past Gyn History.

Physical Exam:

VS: BP 110/60, P 78, regular, RR14, Temp 36.6, Weight 116 lbs.



Pages:   || 2 |


Similar works:

«Coto Foundation Educational Scholarship 2016 Entry Form California State Horsemen’s Association Inc.Contestant Name: Address: Phone #: E Mail: Birth Date: Current Age: Region#: English or Western: CSHA Program you Participate in: Drill Team Name: (if you are currently riding on a team) Parent or Guardian Signature: Horse Park at Woodside Fees Stall Fee— $43.00 Print Parent or Guardian Name: Stall fees includes a stall from noon Friday 8/5/2016 to 3:00pm Sunday 8/7. No day Haul-in, One bag...»

«Quanta Magazine Series: Janna Levin’s Theory of Doing Everything Janna Levin’s Theory of Doing Everything The astrophysicist, conceptual writer and host of standing-room-only scientific soirees at a repurposed factory in Brooklyn sees science as a powerful force in culture. https://www.quantamagazine.org/20160505-janna-levins-theory-of-doing-everything/ May 5, 2016 Quanta Magazine Béatrice de Géa for Quanta Magazine By Natalie Wolchover The astrophysicist and author Janna Levin has two...»

«Clinical (Volume 11) Restraint Minimisation and Safe Practice Restraint Minimisation and Safe Practice Table of Contents Policy Purpose Scope/Audience Associated documents Definitions Restraint Episode of Restraint Chemical Restraint Categories of Restraint Personal Restraint Physical Restraint Environmental Restraint Seclusion Exclusions to this Policy Clinical Responsibilities Divisional Responsibilities Corporate Responsibilities Measurement/Evaluation References –  –  – The...»

«On Mishima Robert S. Griffin www.robertsgriffin.com Yukio Mishima—the three syllables of his last name are pronounced with equal stress(1925-1970) was a Japanese author and playwright, who gained international recognition and acclaim, including being on a short list for the Nobel Prize in Literature. He is most remembered, however, for his ritual suicide at 45 by seppuku (disemboweling oneself with a knife and then being beheaded by a colleague). Mishima wrote voluminouslynovels, plays, and...»

«Quantitative textural analysis of Vulcanian pyroclasts (Montserrat) using multi-scale X-ray computed microtomography: comparison with results from 2D image analysis Thomas Giachetti, Alain Burgisser, Laurent Arbaret, Timothy H. Druitt, Karim Kelfoun To cite this version: Thomas Giachetti, Alain Burgisser, Laurent Arbaret, Timothy H. Druitt, Karim Kelfoun. Quantitative textural analysis of Vulcanian pyroclasts (Montserrat) using multi-scale X-ray computed microtomography: comparison with results...»

«QUALIDADE DO FRUTO vs. QUALIDADE DO SORBET Estudo do efeito do tempo e temperatura de conservação do sorbet. Cátia Vanessa Gonçalves Hipólito Dissertação para obtenção do Grau de Mestre em Engenharia Alimentar Orientador: Professora Doutora Margarida Gomes Moldão Martins Co-orientador: Engenheira Maria do Rosário Carvalho Ramalheira Júri: Presidente: Doutor Victor Manuel Delgado Alves, Professor Auxiliar do Instituto Superior de Agronomia da Universidade Técnica de Lisboa. Vogais:...»

«SIXTH ALUMINIUM TASK FORCE MEETING 22 & 24 MARCH 2010, VANCOUVER, CANADA MEETING RECORD Agenda Item 1 – Welcome and Introductions The Chair of the Aluminium Task Force, Ms Sue Kruse, welcomed participants to the meeting. Ms Kruse advised participants that Mr Stephen Woolcott from the Aluminium Task Force Secretariat had recently changed jobs and was no longer involved in the Task Force. Ms Kruse congratulated the Canadian APP Secretariat and thanked them for hosting the Task Force meeting. Ms...»

«Geology of the northern Plomosa Mountain range, Yuma County, Arizona Item type text; Dissertation-Reproduction (electronic) Authors Jemmett, Joe Paul, 1925Publisher The University of Arizona. Rights Copyright © is held by the author. Digital access to this material is made possible by the University Libraries, University of Arizona. Further transmission, reproduction or presentation (such as public display or performance) of protected items is prohibited except with permission of the author....»

«Sample Study of Informal Scrap Dealers and Recyclers in Bangalore February –April 2011 Contents Background Page 1 Methodology Page 3 Survey Findings Page 5 Map Page 13 Case Studies Page 14 Conclusion Page 22 Annexure Annexure 1Survey questionnaires Page 25 Questionnaire for small/ medium scrap shops study Page 25 Bangalore 2011 Questionnaire for Large scrap shops study Page 26 Bangalore 2011 Interview with Reprocessor Page 28 Annexure 2Maps Page 29 Background India has an age old practice of...»

«RESEARCHED, COMPILED, ANALYZED, PREPARED AND OWNED IN ITS ENTIRETY, SOLELY BY MYSELF: DR. J.D.BEDSOLE,ASME,BSBA,BSVE,MSEA,PhD,And ScD. NOT FOR SALE Copies Furnished To You By Me, Are Free Of Charge Please read the following copyright Note. © COPYRIGHT 1996,1997,1998,1999, 2000, 2001, 2002, 2003,2004,2005,2006, 2007, 2008, 2009, 2010, 2011, 2012 and 2013. JD Bedsole. All Rights Reserved. Copying this booklet is free for your own use, but copying it, or any part of it for sale, or incorporation...»

«Miles, M. 2007-08. “Disability and Deafness in East Asia: Social and Educational Responses, from Antiquity to Recent Times. A bibliography of European-language materials with introduction and some annotation.” (This work revises and greatly extends an earlier bibliography on the former History of Education website at the Catholic University of Nijmegen). Internet publication URLs: http://independentliving.org/docs7/miles200708.html and http://independentliving.org/docs7/miles200708.pdf The...»

«Sermon #1781 Metropolitan Tabernacle Pulpit 1 TWO PAULS AND A BLINDED SORCERER NO. 1781 A SERMON DELIVERED ON LORD’S-DAY MORNING, MAY 18, 1884, BY C. H. SPURGEON, AT THE METROPOLITAN TABERNACLE, NEWINGTON. “Then the deputy, when he saw what was done, believed, being astonished at the doctrine of the Lord.” Acts 13:12. CYPRUS was by no means a reputable island, it was devoted to the goddess Venus, and you can imagine what her worship was, and what would be the fruitful licentiousness which...»





 
<<  HOME   |    CONTACTS
2016 www.dissertation.xlibx.info - Dissertations, online materials

Materials of this site are available for review, all rights belong to their respective owners.
If you do not agree with the fact that your material is placed on this site, please, email us, we will within 1-2 business days delete him.