Tina Sandler – PART 2 – OBGYN
Diagnosis – Prenatal checkup (Pregnancy) – Domestic Violence
Prenat checkup 24w, fall (DV), headache, constipation, hx preeclampsia, hx ectopic preg, hx intrauterine fetal demise, PE – bru
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Tina Sandler – PART 2 – OBGYN
Diagnosis – Prenatal checkup (Pregnancy) – Domestic Violence
Prenat checkup 24w, fall (DV), headache, constipation, hx preeclampsia, hx ectopic preg, hx intrauterine fetal demise, PE – bruise LLQ abd, PE – bruise l breast
Tests- obs us, UA, CBC, TSH
Problem Statement:
( Demographic description – chief complaint – Hx and PE key findings – risk factors )
Tina Sandler is a G5P1 woman presenting at 24weeks gestation for prenatal checkup. She reports falling in a domestic altercation with her intoxicated husband. On physical exam she has a large bruise in her abdomen LLQ, hyperechoic sounds are heard in her abdominal RUQ, fetal heart rate is 140, there is also a 5x5in bruise on her left breast. She reports new headaches and ankle edema on standing. Patient hasa history of ectopic pregnancy and preeclampsia and 3rd trimester loss of pregnancy.
CC: Tina Sandler is a 29 year old G5P1 woman presenting at 24 weeks gestation for prenatal checkup - She reports falling in a domestic altercation with her intoxicated husband.
HPI: Patient reports in a fight with her husband she ‘fell down the stairs’ - On physical exam she has a large bruise in her abdomen LLQ, hyperechoic sounds are heard in her abdominal RUQ, fetal heart rate is 140, there is also a 5x5in bruise on her left breast. She reports new headaches and ankle edema on standing. She describes her headaches as new and starting in the mornings.
Meds: Prenatal vitamins
PMH: Patient has a history of ectopic pregnancy and preeclampsia and 3rd trimester loss of pregnancy.
SH: Patient reports that she is not currently smoking cigarettes, drinking alcohol, or using recreational drugs while pregnant
ROS: Only positive findings are seen in HPI
Physical Exam:
VS: Pulse – 78; BP – 118/78 RR – 14; T – 98.6F (37 C); SpO2 – 94%
Abdomen: A large bruise (4 – 6cm) is seen in LLQ – fetal movement is palpated, fetal heart rate 140bpm. Hyperechoic sounds are heard on auscultation of RUQ of abdomen.
Chest: A large bruise is seen on the Left breast Gynecologic: Speculum exam shows no bleeding. ASSESSMENT/PLAN
Test Results:
• Obstetric ultrasound: Structural survey of pregnancy yields normal results.
• OGTT (Oral glucose tolerance test): Normal – no indication of gestational diabetes
• Urinalysis: UA normal
• CBC, PT/INR, PTT/aPTT: Normal (ordered due to bruising)
• TSH / FT4: Normal
Management Plan
• Continue prenatal vitamins.
• Supportive care for Headaches – notify clinic if increased problems.
• Counsel for manner of delivery
• Psychological analysis with referral to social services.
• Discharge patient only when sure she is in a safe environment.
• Obtain sexual history to evaluate if she is being coerced for sexual activity
10assc/1sh
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