CASE 5 - Positive Pregnancy Test

Question 1

We had not planned to have a baby so soon after marriage. What should I do, doctor?

Answer 1

I understand your anxiety about this unplanned pregnancy.

I suggest that you discuss this with your husband.

As your physician, I want to assure you that I am here to support and advise you in whatever decision you make.

If you wish, I would be happy to discuss your options with both of you.

Question 2

Specific questions to ask:

Answer 2

1. LMP — Menarche — Menstrual history (how often, how long, how much).
2. Pain with periods.
3. Spotting between periods.
4. Contraception.
5. Pregnancy/miscarriages.
6. Sexual activity/partners.
7. Hx of STDs.
8. Postcoital bleeding.
9. Breast discharge/tenderness.
10. Last pap.
11. Planned pregnancy? — desired pregnancy? — Domestic abuse?

Question 3

PEx:

Answer 3

1. HEENT ==> I + palpation of thyroid.
2. CV ==> A.
3. Pulmonary ==> A.
4. Abdo ==> I + A + P.
5. Skin exam ==> I for pigmentation or pallor.

Question 4

Sample closure:

Answer 4

1. Mrs. Parker, on the basis of my observations and what you have told me, it appears that you are pregnant.
2. I will have to repeat a urine pregnancy test to confirm the diagnosis.
3. You last period may not have been a real menstrual period, as spotting can frequently occur in the first trimester.
4. Unfortunately, natural methods of contraception such as pulling out before ejaculation are not very effective.
5. We will also need to perform a pelvic US to estimate the age of the fetus and the expected date of delivery.
6. If you are pregnant, we will check some more blood tests, a pap smear, and some vaginal cultures that we routinely perform in every pregnancy.
7. For now, I recommend stopping alcohol consumption and avoiding intense exercises and excess caffeine.
8. I will be giving you some prenatal multivitamins to take orally, and we will schedule your future prenatal visits.
9. I will be able to advise you further as soon as we receive these tests.

DYHAQFM

Question 5

DDx 1 — Normal pregnacy:

Answer 5

1. Amenorrhea for 6wks.
2. Pos pregnancy test.
3. Bilateral breast engorgement.
4. Nausea and weight gain.

Question 6

DDx 2 — Ectopic pregnancy:

Answer 6

1. Amenorrhea for 6wks.

2. Pos pregnancy test.

Question 7

DDx 3 — Molar pregnancy:

Answer 7

1. Pos pregnancy test.

2. Nausea.

Question 8

Workup:

Answer 8

1. Urine hCG.
2. US pelvis.
3. Breast/pelvis exams.
4. Blood type, Rh, antibody screen.