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Chapter 12 The Pregnant Woman

Case Study

CHIEF COMPLAINT:

My periods are irregular.

History of Present Illness: A 16-year-old high school junior presents to the clinic for evaluation of irregular menses. Her periods were regular until 4 months ago. She first skipped a period then had some light spotting, which lasted for 2 or 3 days, and then it went away. Last week, the spotting returned and lasted 1 day. She has noticed increased tiredness and was nauseated for a few weeks, but it went away a couple of weeks ago. She denies any fever or chills. She denies abdominal pain or vaginal discharge. She has noticed some intermittent low back pain. She has not used any overthe-counter medications to treat the pain. She states that her menses started at age 13; the menses last 5 days on average. She has never been pregnant. She is sexually active and is in a monogamous relationship. She uses oral contraceptives for birth control; her partner uses a condom. She is healthy; she has never taken any medications on a regular basis. She does not smoke; she drinks alcohol on the weekends with friends, but no more than 1 or 2 drinks over the weekend; she has never used illicit drugs.

What parts of the exam would you like to perform? (Circle the appropriate areas.)

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General survey Vital signs Skin Head and neck Thorax and lungs Cardiovascular Abdomen

Breasts and axillae Female genitalia Male genitalia Anus, rectum, prostate Peripheral vascular/extremities Musculoskeletal Nervous system

What physical findings are you looking for to help determine the diagnosis?

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These are the actual findings on physical examination:

General survey Vital signs

Alert, young woman sitting comfortably on the examination table. BP 105/72 mm Hg; HR 75 bpm and regular; respiratory rate 18 breaths/min; temperature 98.5F

Abdomen

Protuberant with active bowel sounds. Soft, nontender, with a palpable mass below the umbilicus; there is no hepatosplenomegaly Liver span is 7 cm in the right mid-clavicular line; edge is smooth and palpable 1 cm below the right costal margin. Spleen and kidneys not felt. No costovertebral angle tenderness.

Female genitalia

No inguinal adenopathy. External genitalia without erythema or lesions; no lesions or masses. Vaginal mucosa pink. Cervix nulliparous, purple, with a clear discharge. Uterus anterior, midline, smooth, and enlarged to 16 cm. No adnexal tenderness. Pap smear obtained. Rectovaginal wall intact.

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Based on this information, what is your differential diagnosis?

1. ______________ 2. ______________ 3. ______________

Mutiple Choice

1. Correct instructions about the self-breast examination (BSE) are:

(A) (B)

Tell the woman that the best time to perform BSE is in the middle of the menstrual cycle Recommend that the best time to perform BSE is 47 days after the first day of the menstrual period

(C) (D)

Tell the woman that if she is pregnant, she should not perform BSE until the baby is born Urge the woman that she needs to do BSE bimonthly unless she has fibrocystic breast tissue

2. You have just completed a vaginal examination of a woman who is 6 weeks pregnant. You read on her chart that her cervix is softened and looks cyanotic. You know that she is exhibiting which of the following signs?

(A) (B) (C) (D)

Chadwicks sign and Hegars sign Goodells sign and Chadwicks sign Hegars sign and Goodells sign Tanners sign and Hegars sign

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3. During your examination of a woman in her second trimester of pregnancy, you note the presence of a small amount of yellow drainage from the nipples. You know that this is:

(A) (B) (C)

Most likely to be colostrum and considered a normal finding this late in her pregnancy A sign of breast cancer Too early in the pregnancy for lactation to begin; the woman needs a referral to a specialist

(D)

An indication that the womans milk is forming

4. When palpating the fundus, you know that:

(A)

Fundal height is usually less than the number of weeks gestation, unless there is an abnormal condition such as too much amniotic fluid present

(B) (C)

The fundus should be hard and slightly tender to palpation during the first trimester After 20 weeks gestation, the number of centimeters should approximate the number of weeks gestation

(D)

Fetal movement should be felt by the examiner at the beginning of the second trimester

5. You are palpating the abdomen of a 35-week pregnant woman and note that the fetal head is facing downward toward the pelvis. You would document this as:

(A) (B) (C)

Fetal lie Fetal presentation Fetal attitude

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(D)

Fetal variety