DOORWAY INFORMATION
Opening Scenario
Tanya Parker, a 28-year-old female, comes to the clinic with a positive pregnancy test.
Vital Signs
BP: 120/70 mm Hg Temp: 98.6°F (37°C)
RR: 14/minute HR: 76/minute
Examinee Tasks
1. Take a focused history.
2. Perform a focused physical exam (do not perform rectal, genitourinary, or female breast exam).
3. Explain your clinical impression and workup plan to the patient.
4. Write the patient note after leaving the room.
Checklist/SP Sheet
Patient Description
Patient is a 28 yo F, married with no children.
Notes for the SP
If asked, tell the doctor that you feel tired all the time.
Challenging Questions to Ask
“We had not planned to have a baby so soon after marriage. What should I do, doctor?”
Sample Examinee Response
“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.”
Examinee Checklist
Building the Doctor-Patient Relationship Entrance
□ Examinee knocked on the door before entering.
□ Examinee introduced self by name.
□ Examinee identified his/her role or position.
□ Examinee correctly used patient’s name.
□ Examinee made eye contact with the SP.
Reflective Listening
□ Examinee asked an open-ended question and actively listened to the response.
□ Examinee asked the SP to list his/her concerns and listened to the response without interrupting.
□ Examinee summarized the SP’s concerns, often using the SP’s own words.
Information Gathering
□ Examinee elicited data efficiently and accurately.
Connecting with the Patient
□ Examinee recognized the SP’s emotions and responded with PEARLS.
Physical Examination
□ Examinee washed his/her hands.
□ Examinee asked permission to start the exam.
□ Examinee used respectful draping.
□ Examinee did not repeat painful maneuvers.
Closure
□ Examinee discussed initial diagnostic impressions.
□ Examinee discussed initial management plans.
□ Follow-up tests: Examinee mentioned the need for a pelvic/breast exam.
□ Examinee asked if the SP had any other questions or concerns.
Sample Closure
Mrs. Parker, on the basis of my observations and what you have told me, it appears that you are pregnant. I will have to repeat a urine pregnancy test to confirm the diagnosis. Your last period may not have been a real menstrual period, as spotting can frequently occur in the first trimester. Unfortunately, natural methods of contraception such as pulling out before ejaculation are not very effective. We will also need to perform a pelvic ultrasound to estimate the age of the fetus and the expected date of delivery. 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. For now, I recommend stopping alcohol consumption and avoiding intense exercises and excess caffeine. I will be giving you some prenatal multivitamins to take orally, and we will schedule your future prenatal visits. I will be able to advise you further as soon as we receive these tests. Do you have any questions or concerns?
History
HPI: 28 yo G0 presents with a positive pregnancy test. Her LMP was 6 weeks ago and was unusually scant. She reports bilateral breast engorgement, poor appetite, nausea with no vomiting, increased urinary frequency, and feeling bloated and fatigued. She is sexually active with her husband only, with coitus interruptus as the only method of contraception. This is an unplanned pregnancy, and she is unsure whether she will continue.
OB/GYN: G0, menarche at age 14, has regular periods 4-5/30. No history of STDs; last Pap smear was taken 8 months ago and was normal.
ROS: Denies abnormal bleeding, abdominal pain, fever, shortness of breath, or change in bowel habits.
Allergies: NKDA.
Medications: Multivitamins.
PMH: None.
PSH: Appendectomy at age 20.
SH: No smoking, 1-2 beers/week, no illicit drugs. Married graduate student; denies domestic violence.
FH: Father is a diabetic. Mother has thyroid problems and obesity.
Physical Examination
Patient appears comfortable.
VS: WNL.
HEENT: NC/AT, PERRLA, no icterus, no pallor, mouth and oropharynx normal.
Neck: No thyroid enlargement.
Chest: Clear breath sounds bilaterally.
Heart: RRR; normal S1/S2; no murmurs, rubs, or gallops.
Abdomen: Soft, nontender, nondistended,
BS, no evidence of guarding or hepatosplenomegaly
Differential Diagnosis
CASE DISCUSSION
Patient Note Differential Diagnoses
■ Normal pregnancy: Any history of delayed periods or amenorrhea in a reproductive-age woman who is sexually active should prompt the diagnosis of pregnancy unless otherwise ruled out. This patient has symptoms of nausea, weight gain, and breast engorgement, all signs of early pregnancy.
■ Ectopic pregnancy: Extrauterine implantation resulting in ectopic pregnancy should always be in the differential diagnosis of women with a positive pregnancy test until intrauterine pregnancy is identified.
■ Molar pregnancy: Molar pregnancies are uncommon. Very high serum β-hCG levels, severe nausea and vomiting, new-onset hyperthyroidism, and a uterus that is larger than expected for gestational age should raise suspicion for molar pregnancy. The diagnosis is usually confirmed by pelvic ultrasound.
Diagnostic Workup
■ Urine hCG: A urine hCG test can confirm pregnancy. Alternatively, a quantitative serum β-hCG can be ordered if an abnormal pregnancy (eg, abortion, ectopic pregnancy, molar pregnancy) is suspected.
■ U/S—pelvis: It is important to confirm the location of the pregnancy (intrauterine vs. extrauterine) and the gestational age in patients with an uncertain LMP or irregular periods. This can also aid in the diagnosis of molar pregnancies, uterine fibroids, and adnexal masses.
■ Breast/pelvic exams: Breast engorgement and galactorrhea are some of the physiologic changes that occur in pregnancy. A pelvic exam needs to be performed to evaluate the cervix (lesions, length, dilation, consistency), the uterus (size, fibroids), and the adnexa (masses) and to collect necessary specimens for cytology, cultures, and PCR studies.
■ Blood type, Rh, antibody screen: To detect antibodies that could potentially cause hemolytic disease of the newborn. Rh(D)-negative women should receive anti-D immune globulin as indicated.
■ CBC: To rule out anemia and to obtain a baseline for hemoglobin and platelets.
■ TSH: Neurologic development may be adversely affected in children born to mothers with hypothyroidism, while maternal hyperthyroidism can lead to fetal and maternal complications.
■ RPR, rubella IgG, HBsAg, HIV antibody: These infections can be transmitted perinatally, and early detection allows for measures that could decrease the possibility of transmission to the fetus. HIV screening should be discussed separately, and the patient’s consent is required in some states. These are standard tests that every woman diagnosed with pregnancy should receive.
■ Pap smear: To screen for cervical dysplasia and cervical cancer. However, since this patient had a normal Pap smear eight months ago, a repeat Pap smear is not necessarily indicated at this visit and could be postponed for another four months.
■ Cervical gonorrhea and chlamydia DNA testing: Early diagnosis and treatment of these STDs can prevent serious neonatal infections.
■ UA, urine culture: Pregnant women with untreated asymptomatic bacteriuria are at high risk of developing pyelonephritis. Therefore, all pregnant women need to be screened even if they do not complain of symptoms of a UTI.