Case #1: Teresa.
History of Present Illness (HPI): Teresa is a 34-year-old Hispanic G2P2002. She presents to your office today at 10-weeks post-partum (PP) for her 6-week PP check. She underwent a C-section for failure to progress following a 20-hour labor with Pitocin augmentation. She was discharged from the hospital on day 2 post-partum without complications. Teresa has had difficulty with breast feeding due to discomfort in her suture line and terrible pain in her right breast since her discharge from the hospital.
She reports occasional chills- she has not measured her temperature at home. Teresa was seen by the lactation consultant while in the hospital but "nothing is working" and her son "cries all the time". She is afraid to feed her son formula as her mother-in-law wants her to "keep trying to breastfeed". Teresa tells you she feels as if she has failed her son- "it was so easy with my first baby, I know my husband thinks I am a bad mother".
Prior medical history: None. Prior surgical history: Appendectomy (2000)
Current medications: Prenatal vitamins, stool softener. Allergies: None
OB- GYN History: NSVD (2019) healthy female 7lb 10oz; C-section healthy male 8 lbs. 8 oz as per HPI.
Menarche age 12, cycle length- 5 days- frequency every 28 days- 4-5 tampons per day. No history of sexually transmitted infections (STDs). History of abnormal pap smear in 2019 which was followed by a normal colposcopy. Last pap (during recent prenatal care) reported normal. HIV negative.
LMP: First PP menstrual cycle last week. Has not resumed sexual activity PP. Contraception history:
Oral contraceptives, condoms.
Social history: Lives with husband, mother- in- law, and children. Stay at home mom. Denies EtOH or recreational drug use, never smoker. Her family speaks Spanish at home; she is fluent in English.
Family history: Unremarkable.
Review of Systems (ROS): Negative except as noted in HPI.
Physical Exam (PE)
VS: BP: 110/70, P: 90, RR: 18, T: 38.4, Weight: 132 lbs.
Teresa's C-section suture line is healing well without erythema or tenderness. No vaginal discharge or lesions, no cervical motion tenderness (CMT), uterus normal size firm and non-tender. On breast exam, you do note an erythematous, swollen, and painful area to the right breast. Her physical exam is otherwise unremarkable. Looking for Online Tutoring?
Case #2: Joanna.
History of Present Illness (HPI): Joanna is a 28-year-old Caucasian G4P1021. She is single, living with her father and 2-year-old daughter. She has a part-time job as a server at the local restaurant; she does not have health insurance. Joanna presents to your office at the community health center today stating she is pregnant and wants to receive OB care. She tells you that she has not yet been evaluated for this pregnancy as she was afraid to take time off from work and did not have enough money to pay for the visit.
Prior medical history: None. Prior surgical history: None
Current medications: None. Allergies: Penicillin
OB- GYN History: NSVD (2021) healthy female 6lb 8oz. Menarche age 10, cycle length- 3 days- irregular cycles since menarche- frequency every 20-30 days- 2-3 tampons per day. No history of sexually transmitted infections (STDs). Joanna's OB history includes two first trimester elective terminations of pregnancy, and 1 term female infant delivered vaginally at 37 weeks. Denies any complications during her prior pregnancy however, she notes that her daughter experienced hypoglycemia and respiratory distress, spending 2 weeks in the Neonatal Intensive Care Unit (NICU).
LMP: Approximately 5 months ago. Contraception history: Condoms "sometimes".
Social history: Lives with her retired father and daughter. Restaurant server. Denies EtOH or recreational drug use. Currently smoking 1 pack of cigarettes/ day (15 pack-year history). She and her mother are still paying for her daughter's NICU stay. The child's father is not involved in any way.
Family history: Mother (deceased age 55)- Type 2 diabetes.
Review of Systems (ROS): Unremarkable with exception of dysuria ("it burns when I pee") over the past 1-week. Denies fever, chills, abdominal or flank pain. Thick white vaginal discharge and "itching" for the past month.
Physical Exam (PE)
VS: BP: 108/68, P: 72, RR: 18, T: 37.3, Weight 144lbs
On physical exam you palpate a fundal height of approximately 20cm with an audible fetal heart tone (FHT) of 160. On speculum exam you visualize a multiparous cervix without lesions; bluish discoloration of the cervix, vagina, and vulva is noted with a thick, white discharge. There is no cervical motion tenderness (CMT) on exam. The uterus is anteverted, non- tender, with fundus palpable at the umbilicus. Joanna's physical exam is otherwise unremarkable.
Wet mount reveals budding yeast. Urine dipstick with 1+ leukocytes, trace blood and 2+ glucose.
Case #3: Monica.
History of Present Illness (HPI): Monica is a 43-year-old African- American G3P2102. She is currently separated from her husband of 20 years and is working full-time as a legal secretary. About 8 months ago, Monica started having irregular periods with heavier than usual flow until she stopped having periods or any vaginal bleeding about 3 months ago. She is currently recovering from a "stomach flu" however, she reports daily nausea, vomiting, bloating and decreased appetite over the past 3 weeks.
She is worried because she has gained 12 pounds over the last 3 months "due to menopause". She comes to the clinic today to discuss menopause symptoms and hormone replacement therapy.
Prior medical history: Hypertension (2010)- well controlled on current antihypertensive
Prior surgical history: Cholecystectomy (2015)
Current medications: Lisinopril 10mg daily. Allergies: None
OB- GYN History: NSVD x 2 (2015, 2019) healthy female 6lb 8oz; healthy female 7lbs 6oz. First trimester miscarriage (9 weeks) in 2014. Menarche age 15, cycle length-7 days- frequency every 28 days- 5-6 pads per day. No history of sexually transmitted infections (STDs). No history of abnormal pap (last pap 2 years ago).
LMP: Approximately 3 months ago. Contraception history: Condoms; past use of oral contraceptives.
Social history: Lives with her elderly father, 2 daughters. Separated from her husband for 6 months.
Family history: Mother deceased (age 60)- breast cancer. Father alive (age 70)- hypertension.
Review of Systems (ROS): Unremarkable with exception of as noted in HPI.
Physical Exam (PE)
VS: BP: 130/78, P: 78, RR: 18, T: 36.1 Weight: 152 lbs.
Physical exam is unremarkable with exception of a palpable 12- 14 weeks size uterus on bimanual. You check a for a fetal heartbeat and obtain a heart tone of 145 via doppler. The intake nurse reports that a urine pregnancy test came back positive.
Monica is in disbelief.
Case #4: Laura.
History of Present Illness (HPI): Laura is a 16-year-old Caucasian G1P0. She presents to your office after missing her second period. She is "worried" as she "always gets her period on time". She is in high school- about to enter the 11th grade. She lives with her grandmother and 2 older siblings. Her urine pregnancy test in clinic today is positive.
Laura is sexually active with her boyfriend; they do not use condoms. He "pulls out" as birth control.
She reports being treated at the health department for chlamydia and gonorrhea earlier this year. She thinks her boyfriend was treated but he is not answering her calls since she told him about the missed periods a few weeks ago. She reports daily nausea, vomiting and dysuria for the past 2 weeks.
Prior medical history: None. Prior surgical history: None
Current medications: None. Allergies: None
OB- GYN History: Menarche age 12, cycle length-7 days- frequency every 30 days- 2 tampons per day.
History of chlamydia and gonorrhea (GC) in the past year. Last pap reported normal at the time of chlamydia/ GC diagnosis. Has not received Human Papillomavirus (HPV) vaccine.
LMP: Approximately 2 months ago. Contraception history: Withdrawal
Social history: Lives with her grandmother, siblings. Denies EtOH or recreational drug use. Currently smoking 1 pack of cigarettes/ day
Family history: Mother deceased at age 42- drug overdose. Father unknown.
Review of Systems (ROS): Unremarkable with exception of as noted in HPI.
Physical Exam (PE)
VS: BP: 110/68, P: 80, RR: 18, T: 37.1 Weight: 110 lbs. (states usual weight 120 lbs.).
Physical exam is unremarkable with exception of a cloudy, yellow mucoid cervical discharge on speculum exam; friable appearance of the cervix with cervical motion tenderness (CMT). You palpate an 8-week size uterus on bimanual.
Laura's urine reveals 2+ ketones, 2+ nitrates, and 3+ leukocytes.
Case 5: Denise.
Denise is a 30-year-old Black female G0 with a history of seizure disorder who presents to clinic for her annual well visit. She is excited to tell you that she is getting married in 2 months and they are planning to start a family "right away". Denise went to see her gynecologist last month who told her she was "young and healthy- not to worry, everything will work out fine". No labs were done at the gyn visit; she hasn't started prenatal vitamins. She comes to see you today as she "wants to be sure that she is up to date on everything she needs" before the wedding.
Prior medical history: Seizure disorder (diagnosed at age 18). Prior surgical history: None
Current medications: Levetiracetam 500mg 2 times a day. Allergies: None
Reports she believes she has had all childhood vaccinations. Has not received COVID or influenza vaccines. She is not sure about Hepatitis B or Tdap.
OB- GYN History: G0. Menarche age 14, cycle length-5 days- frequency every 28 days- 2-3 pads per day.
No history of sexually transmitted infection. Last PAP 2020, no history of abnormal PAP. Has not received Human Papillomavirus (HPV) vaccine. Her only sexual partner is her current fiancé (male). LMP was approximately 2 weeks ago. Contraception history: Condoms.
Social history: Sixth grade teacher. Lives with her fiancé. Denies EtOH or recreational drug use. Has never smoked cigarettes or vaped.
Family history: Mother (age 56) alive and well. Father deceased at age 50 from lung cancer (smoker).
Sister aged 21- healthy. Maternal grandmother alive age 88 (hysterectomy for fibroid uterus). Maternal grandfather deceased age 78 (unknown cause). Paternal grandparents- unknown.
Review of Systems (ROS).
Constitutional: No Weight Change, No Fever, No Chills, No Night Sweats, No Fatigue, No Malaise
ENT/Mouth: No Hearing Changes, No Ear Pain, No Nasal Congestion, No Sinus Pain, No Hoarseness, No sore throat, No Rhinorrhea, No Swallowing Difficulty
Eyes: No Eye Pain, No Swelling, No Redness, No Foreign Body, No Discharge, No Vision Changes
Cardiovascular: No Chest Pain, No SOB, No Dyspnea on Exertion, No Orthopnea, No Claudication, No Edema, No Palpitations
Respiratory: No Cough, No Sputum, No Wheezing, No Smoke Exposure, No Dyspnea
Gastrointestinal: No Nausea, No Vomiting, No Diarrhea, Occasional Constipation (managed with diet), No Pain, No Heartburn, No Anorexia, No Dysphagia, No Hematochezia, No Melena, No Flatulence, No Jaundice
Genitourinary: No Dysmenorrhea, No Abnormal Vaginal Bleeding, No Dyspareunia, No Dysuria, No
Urinary Frequency, No Hematuria, No Urinary Incontinence, No Urgency, No Flank Pain, No Urinary Flow Changes, No Hesitancy
Musculoskeletal: No Arthralgias, No Myalgias, No Joint Swelling, No Joint Stiffness, No Back Pain, No Neck Pain, No Injury History
Skin: No Skin Lesions, No Pruritis, No Hair Changes, No Breast/Skin Changes, No Nipple Discharge
Neuro: No Weakness, No Numbness, No Paresthesia, No Loss of Consciousness, No Syncope, No Dizziness, No Headache, No Coordination Changes. Last reported seizure was 10 years ago. Followed by neurologist- last seen in 2023.
Psych: No Anxiety/Panic, No Depression, No Insomnia. No Memory Changes. Denies Violence/Abuse, No Eating Concerns
Heme/Lymph: No Bruising, No Bleeding, No Transfusion History, No Lymphadenopathy
Endocrine: No Polyuria, No Polydipsia, No Temperature Intolerance
Physical Exam (PE).
VS: BP: 130/84, P: 80, RR: 18, T: 37.1, Weight: 118 lbs. BMI 19.0
General: Awake, alert, and oriented. No acute distress. Well developed, hydrated, and nourished.
Appears stated age.
Skin: Skin in warm, dry, and intact without rashes or lesions. Appropriate color for ethnicity. Nailbeds pink with no cyanosis or clubbing.
Head: The head is normocephalic and atraumatic without tenderness, visible or palpable masses, depressions, or scarring. Hair is of normal texture and evenly distributed.
Eyes: Conjunctivae are clear without exudates or hemorrhage. Sclera is non-icteric. No signs of nystagmus. Eyelids are normal in appearance without swelling or lesions.
Ears: The external ear and ear canal are non-tender and without swelling.
Nose: Nasal mucosa is pink and moist. Nares are patent bilaterally.
Throat: Oral mucosa is pink and moist with good dentition. Tongue normal in appearance without lesions and with good symmetrical movement. The pharynx is normal in appearance without tonsillar swelling or exudates.
Neck: The neck is supple without adenopathy. Trachea is midline. Thyroid gland is normal without masses.
Cardiac: The external chest is normal in appearance. Heart rate and rhythm are normal. No murmurs, gallops, or rubs are auscultated.
Respiratory: The chest wall is symmetric and without deformity. Lung sounds are clear in all lobes bilaterally without rales, rhonchi, or wheezes.
Breasts: Symmetrical. No Masses, Dimpling or Nipple Discharge. No Axillary Adenopathy.
Abdominal: Abdomen is soft, symmetric, and non-tender without distention. There are no visible lesions or scars. Umbilicus is midline without herniation. Bowel sounds are present and normoactive in all four quadrants. No masses, hepatomegaly, or splenomegaly are noted.
Genital: External genitalia is normal in appearance without lesions, swelling, masses or tenderness.
Vagina is pink and moist without lesions or discharge. Cervix is non-tender without lesions. Uterus is anteflexed, non-tender and normal in size. Ovaries are non-tender without palpable masses or enlargement.
Extremities: Upper and lower extremities are atraumatic in appearance without tenderness or deformity.
No swelling or erythema.
Neurological: The patient is awake, alert, and oriented to person, place, and time with normal speech.
Motor function is normal with muscle strength 5/5 bilaterally to upper and lower extremities. Sensation is intact bilaterally. Reflexes 2+ bilaterally. No gait abnormalities are appreciated.
Psychiatric: Appropriate mood and affect. Good judgement and insight. No suicidal or homicidal ideation.
What is your pre conceptual plan for Denise? What are her risks?
Keep in mind that the goal of pre-conceptual care is to reduce the risk of adverse health effects for the woman, fetus, and neonate- optimize health and prevention; address modifiable risk factors, chronic illnesses, and medication safety.