Discuss: Pregnancy Case Review Chart
Discuss: Pregnancy Case Review Chart
Description of the case chosen:
Case #1: Jane
Jane is a 42-year-old G4P2103. Jane is divorced and works long, hard hours as a real estate agent. Jane was having irregular and heavy menses for 6 months, and then they abruptly stopped 3 months ago. Jane has been having nausea and vomiting for 6 weeks but attributed it to having the flu recently. She also admits to gaining about 10 pounds in the last few months and experiencing breast tenderness. Jane comes to the clinic today to discuss menopause symptoms and treatment. During the visit, a urine pregnancy test came back positive. During the exam, you palpate a 16-week-size uterus and get fetal heart tones of 165. Jane is in disbelief.
| Subjective data, identify both given and needed data | Objective findings, identify both given and needed data | Diagnostic or laboratory testing needed with rationales | List of three differential diagnoses with rationales | Medications and or treatments needed with rationales | Patient education needed | Referrals for collaborative care needed with rationales | |
· Make sure to address all sections. Do not leave any section blank.
· Include relevant subjective and physical objective findings.
· Identify appropriate diagnostic and laboratory testing needed.
· List at least three differential diagnoses with rationales for choosing.
· Identify usual medications, treatments, or patient education needed.
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· Determine referrals for collaborative care.
· Summarize the case study and include any further research, diagnostics, procedures, or follow-up needed.
· Provide evidence-based references.
Complete the following chart:
MN577 Unit 9 Pregnancy Case Review Chart
Description of the case chosen:
Case #1: Jane
Jane is a 42-year-old G4P2103. Jane is divorced and works long, hard hours as a real estate agent. Jane was having irregular and heavy menses for 6 months, and then they abruptly stopped 3 months ago. Jane has been having nausea and vomiting for 6 weeks but attributed it to having the flu recently. She also admits to gaining about 10 pounds in the last few months and experiencing breast tenderness. Jane comes to the clinic today to discuss menopause symptoms and treatment. During the visit, a urine pregnancy test came back positive. During the exam, you palpate a 16-week-size uterus and get fetal heart tones of 165. Jane is in disbelief.
| Subjective data, identify both given and needed data | Objective findings, identify both given and needed data | Diagnostic or laboratory testing needed with rationales | List of three differential diagnoses with rationales | Medications and or treatments needed with rationales | Patient education needed | Referrals for collaborative care needed with rationales | |
· Make sure to address all sections. Do not leave any section blank.
· Include relevant subjective and physical objective findings.
· Identify appropriate diagnostic and laboratory testing needed.
· List at least three differential diagnoses with rationales for choosing.
· Identify usual medications, treatments, or patient education needed.
· Determine referrals for collaborative care.
· Summarize the case study and include any further research, diagnostics, procedures, or follow-up needed.
· Provide evidence-based references.
