N675L PBL: Obstetrics Answer Key and Tips

PBL: Obstetrics Answer Key and Tips Day 1 Questions 1. What are some of the interventions you plan to do during the initial visit?  Check urine for pregnancy  Comprehensive health history. Because Mary is established in your clinic, you may just need to review some of her medical health hx, and focus on her obstetric history: o Previous OB hx o Family genetic hx o Psychiatric disorders o Contraceptive hx o Medications taken since LMP, menstrual hx o Social habits, environmental exposures, domestic abuse o Sources of social support and health promotion  Depending on time, the PE may also be performed. Many practitioners have the pt return in 2 weeks to perform a PE d/t the time taken for history and blood tests. o CBC, rubella titer, HIV (with pt’s consent), syphilis (rapid plasma reagin or RPR), Hepatitis B surface antigen (HBSAg), blood type and Rh factor, antibody screen, tuberculosis testing, urine culture and sensitivity and BV screening. o Optional labs: HgbA1c, thyroid profile and Hepatitis C o This is also the time to advise Mary on the pregnancy – health promotion, dietary recommendation, exercise, smoking, etc. This includes normal changes, discomforts, and concerns during pregnancy. Even if this is not her first pregnancy, Mary should have a review of these items. 2. What physical exam would you do on this visit? Include your rationale for performing a specific PE, if any.  Depending on time, the PE may not necessarily be performed during this initial visit. However, if time permits, other tests can be performed with the PE.  PE: VS, note postural hypotension and tachycardia o Inspect general appearance, examine peri-pad to determine amt of bldng o Palpate abd (rebound, signs of internal hemorrhage, uterine size (measure fundal ht)) o Check iliopsoas and obturator muscle tests. o Auscultate heart, lungs, and bowel sounds o Pelvic exam – Assess for Chadwick’s sign, look for vaginitis/cervicitis and other s/s of infections that could be causing the bldng.  Bimanual exam: Check Hegar’s sign, evaluate cervical dilatation, CMT (often present with ectopic pregnancy), and bulging cul-de-sac (represents hemoperitoneum); adnexal mass is present in 50% of ectopic pregnancy. 3. What are some of the questions you would ask Mary that is specific to a pregnant pt? This study source was downloaded by from CourseH on :49:54 GMT -05:00  Per above comment, but primarily: nutritional habits, FH of congenital anomalies and heritable diseases, prior STDs  Recent travel to determine the possibility of exposure to the Zika virus  Screen for domestic violence (DV) Additional Information that you may find useful: G: gravida (number of pregnancies) P: para (number of births of viable offspring) A or Ab: abortions T – term births P – preterm births (prior to 37 weeks gestation) A – abortions L – living children GPAL – usually shortened version utilized Day 2 CC: Worsening cramps PE: 100/65 – 37.8 – 100 – 24 – 98% Currently at 5/10 Note for postural hypotension and tachycardia. Hemodynamic instability may be noted in cases of profuse bleeding. Be on alert for hypotension, tachycardia, tachypnea, and/or labored breathing. A pregnant pt does not demonstrate s/s of hypovolemic shock until she has lost 30% of her circulating volume. Gen: A&Ox4, anxious, guarding abd ENT: PERRLA, conjunctiva pink and moist. Oral mucosa pink, moist, neg LAD Skin: Diaphoretic Pulm: CTAB CV: Tachy 104, GI: Hypoactive bowels, neg Cullen’s sign, abd soft, tender to touch lower quads, neg rebound GU: Wearing large peri-pad, slightly saturated In the United States, undiagnosed or undetected ectopic pregnancy is one of the most common causes of maternal death during the first trimester. Prepare pt for emergency transport to a hospital even if she is hemodynamically stable. Dx: Ectopic pregnancy Questions 1. What are your differential diagnoses (ddx)?  First trimester vaginal bleeding – Threatened/Inevitable/Spontaneous abortion, hydatidiform mole, benign or malignant genital tract lesion, genital trauma  Acute appendicitis, acute pelvic inflam