Mn577 pregnancy chart: case study
Patient Information |
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Name: Jane |
Age: 42 |
Gravida: 4 |
Para: 2 |
Abortions: 1 |
Live births: 2 |
Occupation: Real Estate Agent |
Chief Complaint: Irregular and heavy menses for 6 months, abrupt cessation of menses 3 months ago, nausea and vomiting for 6 weeks, breast tenderness, and menopausal symptoms |
History |
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Medical History: Unknown |
Surgical History: Unknown |
Allergies: Unknown |
Medications: Unknown |
Family History: Unknown |
Social History: Divorced, Occupation – Real Estate Agent |
Examination |
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General: Appears healthy |
Vital Signs: Unknown |
Skin: Unknown |
HEENT: Unknown |
Neck: Unknown |
Cardiovascular: Fetal heart tones 165 |
Respiratory: Unknown |
Abdomen: Palpable uterus size 16 weeks |
Pelvic: Unknown |
Extremities: Unknown |
Neurological: Unknown |
Diagnosis |
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Pregnancy |
Menopausal Symptoms |
Treatment |
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Referral to OB/GYN |
Prenatal care |
Education on nutrition and lifestyle changes |
Management of menopausal symptoms |
Follow-up |
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Follow up with OB/GYN for prenatal care |
Follow-up with primary care physician for management of menopausal symptoms |
Monitor weight gain and symptoms of nausea and vomiting |
Additional Information |
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Jane is surprised and may have mixed feelings about the pregnancy due to her age and current life situation. Counseling and support may be needed. |
The cause of Jane’s irregular and heavy menses prior to pregnancy should be investigated, possibly through blood tests or imaging. |