Relaxing in Human Pregnancy, Essay Example

Chief complaint: Absence of menstration (amenorrhea) for five months and general malaise.

History of present illness: – Ms. S. Tis a 22 year old African American female who presented with a history of having no menstrual period for five months. Subsequently, she has been feeling lethargic and tired often. During this time she observed breast tenderness accompanied by enlargement in the lower abdomen. Initially there was frequency in urination without pain or burning.  Nausea was experienced early in the day. Further, she related being sexually active for more than four years. During this time she has changed two boyfriends, but presently has one sex partner.

S.T.explained that she can remember missing periods, but not for such a long time. Besides, whenever she is about to have a period her breast becomes tender and slightly encouraged. It has now caused some concern because her breasts have begun to swell and she is vomiting in the mornings. Sometimes during the day when she smells spicy foods it tends create nausea. Since then she has reduced the frequency of sexual contact, because sexual intercourse is now uncomfortable due to increase in abdomen size, breast encouragement andtendency to vomit. Apart from this medical concern she considers herself relatively healthy. Denies any back, chest, or neck pains; colds, coughing, fever, or chills.

Medications

OTC: – none

Allergies

No known allergies

Past history

Past medical History:-

S.T. reported that she was a 10 pound baby. There was no reason attached to this occurrence except that she added, perhaps, because she was the first child for her mother.Growing up she was always bigger than the children her age and relatively healthier because she eat a lot. Often S.T‘s weight had to be controlled through care monitoring of what she ate since she had a tendency of being overweight. Besides being heavy she was taller than the children her age because both parents were 6 feet and over. Between the ages of 3-5 she was considered 90% taller and weighed 80% more than children in that age group.  However, when approaching puberty after being placed on a rigid nutrition program S.T’s weight was stabilized in relation to age, but her height remained the same being relatively taller than her peers.She reported being skinny, which was not to her liking.

Past surgical history:-

S.T reported that at age 8 she developed acute appendicitis, which was treated surgically by removal of the appendix.The 22 year old recalled being hospitalized for two weeks and in rehabilitation for other two weeks. Since this surgery there has been no further pain in the abdominal region and vomiting of bile substances which was experienced at the time during her illness. Also, she reported taking large doses of antibiotics to kill the bacteria causing this inflammation.

Personal social history:-

S.T graduated high school four years ago as an honor student. Since then she attended a four year college pursuing a bachelor’s degree in pharmacy. Presently, she works at a city pharmacy under the supervision of a qualified pharmacist dispensing prescriptions. Even though she was rasied Christian S.T confessed that loves to parting because she felt secluded having only to go to church. There was no scope of learning about other things of life which were termed sinful. As such she takes opportunities visiting the night clubs when she is off duty.

At a very early age she was baptized into the Baptist Christian tradition because both parents are from that faith. However, she explained that there were many concerns regarding the God projected in the bible. So by age 16 she stopped believing in the church doctrine and began exploring a God presence of her own. While she still lives with her parents their religious beliefs conflict. Besides, she admits being somewhat confused about life and its experiences, which pushes her into several relationships trying to find herself.

Family history

S.T. is the first of six children and only girl. Her father being a lay minster in the Baptist church is considered very strict. The other five boys range from the ages 20 – 10 years old. Two graded high school and are currently attending college. One is in high school, another in Middle and the youngest in elementary. They are all doing relatively well. Her mom is an elementary school principal while the father is an immigration officer attached to homeland security.

Mother is relatively healthy at 51;father is 53 and strong. Siblings are healthy with no medical diseases There no grandchildren as yet in the family.  All of S.T’s grandparents are alive. The maternal grandparents are at age 73 and 75 respectively. The paternal grandparents are 75 and 80 years old respectively with no serious medical conditions such as diabetes, hypertension, COPD. They are all Christians from the Baptists tradition.

Immunization:-

S.T. obtained all vaccines as a child. She has health insurance coverage from her job. As such she visits her primary care physician regularly for routine screening.

Review of systems:-

General – mildly overweight; recent weight increase of 5 lbs., no fever, mild fatigue,  andweakness.

Skin: no eczema, discoloration, sores, itching or dryness.

Eyes: Most recent vision check one year ago. S.T. believes  she has 20/20 vision. Sees perfectly to read in the dark and tolerates looking at the sun with no discomfort to the eyes.

Ears: Has had earing check one month ago and denies any changes in hearing ability, recently; exudate from ears or tinnitus. No ear pressure disclosure.

Nose: S.T has a slightly broad nosethat looks odd sometimes due to the African heritage. It creates no breathing problems. Therefore, no cosmetic septum repairs are necessary to correct it. Further, she denies any nasal congestion. However, when feeling cold a clear nasal discharge may be produced until the cold symptom subsides. She denies any nose occasional bleeding.

Throat: Denies soreness in throat, hoarseness, bleeding gums, dry mouth, swelling and pain.

Neck: No abnormalities reported. S.T denies swelling; pain or numbness.

Respiratory: S.T denies any wheezing, shortness of breath, asthmatic episodes or rales.

Cardiovascular: denies palpitations, edema, pain in the chest, difficulty breathing upon exertion. S.T reports normal heart rate and normal blood pressure readings, which she takes regularly at the local Wal-Mart store pharmacy where she works. This is a precautionary measure since she has the tendency of being overweight.

Gastrointestinal: S.T denies diarrhea or constipation. She repots having a bowel movement every day or every other day from birth, but recently experiencing periods of nausea and vomiting.

Endocrine: S.T denies any irregularity in menstrual flow, thyroid dysfunction or adrenal function, but has had no menstrual flow for the past five months.

Objective Data:

T: 36.5 Celsius (oral), BP 110/ 65 P: 96, RR: 16, wt:  200 lbs. height 6ft 2inches

Generalized appearance. R.T appears healthy; well groomed; articulate with a huge plump body; glowing appearance; dimpled smile accompanied by a piercing eye contact.

 Skin:  Clean, clear, consistent, with no discolorations, rashes, acne or abnormality.

Head: Normocephalic, Atraumatic.

Ears: Tympanic membranes appeared gray, non-bulging with free mobility with no erythematous; ear canal patent bilaterally. A very small amount of cerumen was seen. no unusually discharge neither odor was observed.

Nose: Nares were observed to be patent bilaterally with no nasal discharge or odor.  The mucosa was observed to be pink and moist; septum midline normal; no presence of oedema was detected edema above frontal or maxillary sinuses. Upon percussion of sinuses tenderness was observed.

Pharynx: Oral mucosa appeared pink, moist.  No erythema, exudate, or lesions was seen in the Posterior oropharynx. The Tonsillar pillars were 2+ without exudate and the uvula rose evenly; Gag reflex normal and no hoarseness observed.

Neck: Upon palpation non-tender was observed and no lymphadenopathy, masses or thyromegaly.

Cardiac:  Heart beat evaluation revealed that it was regular and rhythmic with no murmurs; normal S1 and S2. Also, S3, S4 murmurs were not detected. Upon observation no peripheral edema, cyanosis or pallor were detected. Extremities were warm and fully perfused with capillary refill less than 2 seconds and carotid bruits none existent.

Respiratory: respirations were normal and regular without difficulty. Chest expansion was symmetrical with clear bilaterally auscultation. Rhonchi, rales, diminished breath sounds or wheezing were observed.

Abdominal:This abdomen appeared firm, distended, and non-tender throughout the palpation. The uterus could be felt in the abdomen midway between the symphysis pubis and the umbilicus which could be estimated to be about 20-22 weeks in size. Otherwise no masses felt, spleen size was normal and bowel sounds positive. Fetal heart heard.

.GU: Not assessed.

Neuro: S.T’s gait expressed normal mobility and she was fully oriented to time and place.

Labs: glucose 105, Hemoglobin A1C 11.4, Triglycerides 409.  Pregnancy test positive, HIV positive; gonorrhea, nucleic acid amplification tests (NAAT) negative; nucleic acid hybridization test (DNA probe test, molecular probe test), negative; Gonorrhea culture 0; Urinalysis, bacteria 0; syphilis negative; HB 12gms.

Assessment:

Primary diagnosis:  Pregnancy with HIV

Pregnancy in humans occurs when there is fertilization and development of the female embryo whereby a fetus is formed. For scientific purposes pregnancy has been divided into three trimesters; the first being months 1-3, second; 4-6 and third 7-9. From the assessment conducted on S.T she is in the second trimester of ther pregnancy. Precisely this is diagnosed by physical changes in the body along with supportive laboratory results. Levels of the human chorionic gonadotropin (hCG) hormone are evaluated in determining whether pregnancy has occurred. The test is only accurate after implantation of the embryo has taken place (Goldsmith & Weiss, 2013).

After ten weeks gestation (being in the uterus) the embryo is termed a fetus. Many complications can occur during pregnancy and other disease conditions do affect the management and outcome ultimately.  In S.T’s situation she is pregnant for the first time and is HIV positive. An HIV infection in a pregnant woman as S.T. can progress to AIDS as well as cross the placental barrier infecting the fetus.HIV is transmitted (passed) through specific body fluids such as blood, semen, genital fluids, and breast milk. Unprotected sex with an infected person transmits the virus(AIDS info, 2013).

Differential Diagnoses

1. Pseudocyesis

Pseudocyesis is also termed false pregnancyhysterical pregnancy or phantom gestation. The symptoms are similar to true pregnancy inclusive of amenorrhea; morning sickness; weight gain; abdominal distention and breast tenderness. These symptoms resolve when the woman is placed under general anesthesia. Pregnancy tests are usually negative (Tarín, Hermenegildo & García-Pérez, 2013).

2. Ovarian cysts/tumor

Ovarian cysts/ tumors emerge from the ovaries. Some can be benign while others are malignant. Signs and symptoms include pain and bloating of the abdomen; frequency and difficulty urinating; dull lower back pain; weight gain; painful sexual intercourse, nausea and vomiting (Kaijser, Sayasneh, Van Hoorde, Ghaem-Maghami, Bourne, Timmerman & Van Calster, 2013).

3. Uterine Fibroid

Uterine fibroid is a benign growth emerging from the smooth muscle within the uterine cavity. Signs and symptoms include abnormal bleeding; abdominal bloating; painful urination and defecation; frequency in micturition and intercourse. Fibroids during pregnancy can predispose to placenta previa, threatened abortion and prematurity (Kaijser et.al. 2013)

Plan

• Refer S.T to a gynecologists for further evaluation and management of pregnancy with HIV.HIV pregnant women have access to medications during pregnancy that would prevent their unborn from becoming infected(AIDS info, 2013).
• Education and counseling. Inform S.T’s primary care concerning her HIV status and management after pregnancy.

Reflection notes

A comprehensive assessment of Ms. S.T’s condition was conducted according to the principles contained in the SOAP assessment protocol. However, while I am satisfied that this was a thorough objective assessment, perhaps, discussion regarding how she perceived her HIV status could have been entertained in determining her psychology of her situation being a Christian trying to find herself outside of church.

References

AIDS info. (2013). Fact sheet. retrieved on May, 17^th, 2014 from http://aidsinfo.nih.gov/contentfiles/Perinatal_FS_en.pdf

Goldsmith, L., &Weiss, G. (2013).Relaxin in Human Pregnancy.Ann N Y Acad Sci

Gorman, S. (2013).A new approach to maternal mortality: the role of HIV in pregnancy.Int J Womens Health. 5: 271–274.

Kaijser, J. Sayasneh, A. Van Hoorde, K. Ghaem-Maghami, S. Bourne, T. Timmerman, D., & Van Calster, B. (2013). Presurgical diagnosis of adnexal tumours using mathematical models and scoring systems: a systematic review and meta-analysis”. Human Reproduction Update 20 (3): 449–462.

Tarín, J. Hermenegildo, C., & García-Pérez, M. (2013).Endocrinology and physiology of Pseudocyesis.Reprod Biol Endocrinol, 11: 39