Subjective data
Identification: K.G. is a pregnant 23 year-old Caucasian female.
Chief complaint: Ms. G. enters the clinic today for a routine obstetric exam.
History of present illness: Ms. G. is 34 weeks pregnant and is a G1 P0. Last menstrual period was 10/23/13.
Past Medical History: The patient has a history of gestational thrombocytopenia.
Past Surgical History: Ms. G. had a benign cyst removed from her anterior neck in 2013.
Family History:
Ms. G. states that her mother and father both alive and her father has a history of asthma. Ms. G. states that her mother has rheumatoid arthritis.
Ms. G. is an only child.
Social History: Ms. G. is single. Ms. G. does not smoke or drink alcohol. Ms. G. does not use or has never used illicit drugs. Ms. G. works full-time in the banking industry. Ms. G. does not participate in any form of exercise on a regular basis.
Current medications: Ms. G. states that she does take prescription medications. The patient takes prenatal vitamins.
Allergies: Ms. G. states she has no medication allergies.
Review of Systems
General: Ms. G. has gained 30 Lbs. with this pregnancy. Ms. G denies any fever or chills. Ms. G. does have normal pregnancy fatigue.
Skin: The patient denies any rashes or lesions. The patient denies any changes in moles or skin growths.
Head, eyes, ears, nose and throat: The patient denies any sore throat, cough, congestion. The patient does not wear contact lenses or glasses. The patient denies any visual changes. The patient denies any nasal discharge or epistaxis. The patient denies any difficulty swallowing.
Mouth and teeth: The patient denies any ulcers or sores in mouth. The patient denies any dental problems. The patient denies any dysphagia.
Neck: The patient denies any pain in the cervical area. The patient denies any decrease in range of motion or stiffness in the cervical area. The patient denies any difficulty swallowing.
Lymphatic: The patient denies any pain or swelling of lymph nodes.
Breasts: The patient denies drainage from nipples. The patient denies any lumps or noticeable masses.
Respiration: The patient denies any shortness of breath or breathing difficulties. The patient denies any cough.
Cardiovascular: The patient denies palpitations, syncope or orthopnea. The patient does not complain of chest pain.
Gastrointestinal: The patient denies constipation or diarrhea. The patient denies any recent nausea or vomiting.
Genitourinary: The patient denies dysuria. The patient denies any hematuria. The patient denies any rashes or lesions in the genital area.
Endocrine: The patient denies heat/cold intolerance, denies thyroid problem or diabetes mellitus. The patient denies polydipsia or polyuria.
Hematologic: The patient denies bruising easily or excessive bleeding.
Musculoskeletal: The patient denies weakness or difficulties with ambulation.
Peripheral vascular: The patient denies any numbness or tingling in hands or feet. The patient denies cold feet or hands.
Neurological: The patient denies any numbness, tingling or loss of sensation. The patient denies loss of consciousness or syncope episodes.
Psychiatric: The patient denies any depression, anxiety or memory loss. The patient denies any suicidal ideations or desires to harm others.
Physical Examination
General appearance: The patient is a pregnant, adult female. The patient appears healthy. The patient is alert and in no acute distress.
Vital Signs: The patient has a blood pressure reading of 101/62 mmHg and a resting pulse of 86 beats per minute. The patient has a respiration rate of 18 breaths per minute and a temperature of 96.9 tympanic reading. The patient is 52” tall and weighs 135 lbs.
Skin, Hair and Nails: Skin is intact with no bruising or wounds noted. Skin tone is normal for the patient. The skin is dry, intact and appears to be well perfused, normal turgor with no tenting noted. There are no moles or suspicious lesions observed. Nails are strong and well groomed.
Head, eyes, ears, nose and throat: Head: Head is normocephalic, no evidence of trauma, with no nodules or abnormalities noted. The patient has a full head of red/brown hair with no areas of thinning. The texture is normal for the patient with no noted changes in texture.
Eyes: Pupils are equal, round and reactive to light bilaterally. EOM intact, accommodation is within normal limits. Lids normal with no ptosis noted. Sclera clear, conjunctiva pink with no lesions noted.
Ears: External ear canals are clear with no cerumen noted in either canals. Tympanic membranes are intact bilaterally. Tympanic membranes are pink with no inflammation noted.
Nose: Nasal septum intact and midline with no lesions noted. Turbinates’ are pink and intact bilaterally, with no lesions noted.
Throat: The neck is supple and trachea is midline. No masses or enlarged lymph nodes noted in the throat area. Tonsils are visualized without any swelling or erythema noted.
Mouth and Teeth: Oropharynx pink and moist, no plaque or ulcers noted. Good dentition noted. Cranial Nerve XII intact.
Neck: Neck is negative for masses and gland enlargement. Trachea is midline with no deviation. No bruits noted in carotid arteries. No tenderness noted in the cervical region. No enlargement of thyroid noted.
Lymphatic: There is no lymphadenopathy present. Thorax and Lungs: Thorax is symmetric with resonant lung sounds. The patient has clear breath sounds with no crackles or wheezing heard. The patient is able to take deep and full breaths.
Cardiovascular: Jugular venous pressure was not measured. The patient has brisk carotid upstrokes without bruit. The patient has a good S1 and S2 with no S3 or S4. The patient does not have a murmur, systolic or diastolic. Heart beat is regular rhythm with no irregularities.
Peripheral vascular: The patient has warm extremities that are without edema and pink color. No cyanosis or cool extremities observed. Capillary refill is less than 3 seconds upon blanching of the fingernails.
Breasts: The breasts appear symmetrical with no nipple discharge. There are no masses noted on examination.
Abdomen: Abdomen is protruding with a fundus height of 33cm. Active bowel sounds in all four quadrants. Fetal movement noted on slight palpation. Fetal heart tones detected at a rate of 152 bpm.
Musculoskeletal: The patient has no joint deformities with good range of motion. No redness or swelling noted on any joints.
Genitalia: Exam was deferred.
Neurological: The patient is alert, cooperative and quickly answers questions. The patient is oriented to person, place, and time.
Diagnostic Testing: No diagnostic testing was performed during this visit. Fetal heart tones and fundus measurement were obtained.
Assessment
The patient presents to the clinic for a regular obstetric appointment. The patient does not have any complaints at this time. Follow up of recent lab results were discussed and patient was educated on her previous low platelet count and will continue to monitor low platelet counts as well as low Hematocrit and hemoglobin levels. The patient’s initial lab results from 6/5/14 included red blood cell count (RBC) of 3.66, hemoglobin 10.7, hematocrit 32.2, platelet count of 87 k/ul., a normal platelet count is 150-400. Follow up lab results from 6/10/14 reveal a RBC of 3.42 normal range is 4.2-5.4, hemoglobin is 10.1 with normal ranges 12.0-16.0 and hematocrit 29.4 and normal range is 37.0-47.0. Platelet count was 95 and normal count is 150-400 k/ul, all other lab results were within normal limits. This patient was also assessed for any signs of headache, visual disturbances and elevated blood pressure. These signs along with thrombocytopenia can be a sign of preeclampsia and HELLP (hemolysis, elevated liver enzymes, and low platelet count) syndrome (Gauer & Braun 2012). The patient denied any other symptoms and her blood pressure was within normal limits with a reading of 101/62.
Primary Diagnosis:
Gestational thrombocytopenia: Gestational thrombocytopenia is the primary diagnosis for this patient based on lab results. Thrombocytopenia in pregnancy is defined as a platelet count under 150 k/ul and is common in pregnant women (Shamoon, Muhammed, & Jaff, 2009). Thrombocytopenia is the second most common diagnosed hematological disorder during pregnancy, with anemia being the most common disorder diagnosed (Ajibola et al., 2014). Platelet counts in pregnant women are normally slightly lower than their non-pregnant peers (Meyers, 2012). Patients with gestational thrombocytopenia are at a greater risk for bleeding during delivery and post-partum complications (Berkley & Kilpatrick, 2009). Risks are not increased unless platelet count drops below 50k/uL at the time of delivery or cesarean section (Berkley & Kilpatrick, 2009). This patient will be able to have an epidural and vaginal or cesarean section if her platelet count of 100 k/uL at the time of labor and delivery per her obstetrician’s protocol. Mild thrombocytopenia in pregnancy does not usually increase risk of complications, but it can become severe and be life threatening for the mother and baby (Meyers, 2012). Differential Diagnosis:
Preeclampsia/HELLP (hemolysis/elevated liver enzymes/low platelets) syndrome: Preeclampsia/HELLP is a multi-system disorder that affects 2-7% or pregnancies (Young, Levine, Salahuddin, Qian, Lim, Karumanchi & Rana, 2010). Preeclampsia initial symptom is increased blood pressure over 140/90 mmHg on at least two different occasions (Savaj & Vaziri, 2012). Proteinuria over 300 mg/dL in 24 hours is another significant finding in preeclampsia (Jido & Yakasai, 2013). Causes of preeclampsia are still not completely known but the risk factors for preeclampsia include hypertension, antiphospholipid syndrome, diabetes mellitus are predisposing factors (Savaj & Vaziri, 2012) It is believed that early onset preeclampsia are related to fetal abnormalities and late onset (after 34 weeks) is due to a maternal abnormality (Savaj & Vaziri, 2012) Preeclampsia can cause serious health issues as well as fetal and maternal fatality if not treated quickly (Jido & Yakasai, 2013). Symptomatic treatment of symptoms of high blood pressure and seizure control while in the preeclampsia state is the goal for gestational age of under 34 weeks (Savaj & Vaziri, 2012). Delivery of the baby is the only resolution to the symptoms of preeclampsia and eclampsia (Jido & Yakasai, 2013).
Anemia: Anemia is defined as a low level of hemoglobin in the blood and a reduced number or reduced quality of red blood cells (Kozuki, Lee, & Katz, 2012). Pregnancy affects hemoglobin levels by increased blood volume to accommodate uteroplacental circulation (Kozuki, Lee, & Katz, 2012). As the plasma volume increases throughout the pregnancy the hemoglobin levels decrease until around the 30th week when hemoglobin production is stabilized (Kozuki, Lee, & Katz, 2012). Anemia during pregnancy is thought to be due to a deficiency and iron supplements can help prevention of anemia (Ouédraogo et al., 2012). Severe anemia during pregnancy can cause intrauterine growth delay, preterm birth, increase in preterm birth as well as increase in infant mortality (Ouédraogo et al., 2012).
Plan
Medications: The patient was referred to Dr. Quick who specializes in hematology. Dr. Quick ordered a RhoGAM injection on June 10th and lab was performed prior to the Rhogam injection. The patient will have more lab work drawn in three weeks. Lab work will include a CBC with differential. If lab results show abnormal results at that time the patient will receive another RhoGAM injection at that time. Lab tests will be ordered at the time the patient goes into labor and if results indicate a need, platelets will be administered at the time of admission to the hospital for delivery. The patient will continue to be seen by Dr. Quick and he will actively monitor patient for ongoing needs. The patient will continue to be seen in this office every 2 weeks until referral to her obstetrician at 36 weeks gestation for her ongoing care and delivery of baby.
Follow up: The patient should follow up in two weeks for another office visit for fundus height measurement and fetal heart tones. The patient will also follow up with Dr. Quick in three weeks.
Education:
The patient is educated on lab results and future injection schedule. The patient is also educated that she will be unable to receive an epidural at the time of birth, if her platelet count is below 100 k/ul, due to increased risk of bleeding. The patient is also educated on fetal kick counts which helps assess the baby’s movements. Breast feeding education was also discussed during this office visit. The patient was also advised of signs and symptoms of preeclampsia which include high blood pressure, severe headache, visual disturbances and right upper quadrant pain (Thangaratinam et al., 2011). The patient is advised if these symptoms occur to go immediately to labor and delivery due to the increased risks to mother and baby.
Theoretical Framework The theory that applies to this patient is Joyce Travelbee’s human-to-human relationship model. Travelbee states that nursing begins in an initial encounter and emerges through the relationship (Editor, 2013). Caring for an obstetric patient is building a strong relationship of trust and caring. The patient relies on the practitioner to guide them in their care and any unexpected circumstances. The practitioner develops an empathy and sympathetic relationship with the patient. This patient was also educated about her condition and encouraged about the outcome of her pregnancy and given the necessary information to have a positive outlook for the progression of her pregnancy. Another aspect of Travelbee’s human-to-human relationship model addresses a rapport with patients. This patient and practitioner have an excellent rapport and the patient feels at ease and confident with what the practitioner is advising about treatment and expected outcomes of the pregnancy and complications that have arisen.
References
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Berkley, E., & Kilpatrick, S. (2009). Thrombocytopenia in pregnancy: making the differential diagnosis. Contemporary OB/GYN, 54(1), 36.
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Gauer, R., & Braun, M. (2012). Thrombocytopenia. American Family Physician, 85(6), 612-622.
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