Week 4 reply

Darynara

Jennifer is a G2P1, 31-year-old pregnant female at 24 weeks EGA who has come to the clinic for her 24-week prenatal visit and recommended screening tests. Jennifer’s one hour glucose test result is 156 mg/DL. Her BP is 118/78 T 98.7 F, P 68, RR 18, fundal height is 25 cm, no urine/protein in urine, weight is 145 lbs at 5 lbs increased from last visit 4 weeks ago, her height is 5’ 5”.  

Subjective

CC: 24 week prenatal visit, no complaints 

HPI: 31 y/o F, G2P1 presents to clinic for her 4th prenatal visit at 24 weeks. Todays visit reveals vitals signs WNL, fundal height  is measuring in accordance with gestational age, patient is in normal weight category with expected weight gain from last visit. Abnormal: one hour glucose test result is 156 mg/DL. 

What other relevant questions should you ask regarding the HPI?

Do you have any symptoms or health concerns at this point? 

What other OB history questions should you ask?

Gyn/OB history: 

G2P1

EGA 24 weeks 

Any hx of GDM with previous pregnancy? 

Any Hx of prior birth of an infant weighing >4000 gms

Any hx of prior birth to infant with congenital abnormalities? 

Any hx of PCOS? 

What other medical history questions should you ask?

PMH: denies 

Do you take any new medications, including OTC or supplements

Any new allergies?

Any history of DM Type 1 or 2 or metabolic syndrome?

Any hx of cardiovascular disease? 

Any hx of Hyperlipidemia?

Any hx of HTN? 

Family Hx: denies 

Any family hx of first degree relatives with DM or GDM? 

Social Hx: 

Do you drink, smoke, use drugs? 

How much of a physical activity you get daily? 

How is your diet? 

Do you have access to nutritious food? 

What do you do for work? 

Do you have a good support system, people you feel comfortable talking to if you have problems?

ROS

General: : Denies fever, chills, unintentional weight loss.
 Do you experience excessive tiredness? 

HEENT: Denies changes in vision and hearing, sore throat, and dysphagia

Cardiovascular: Denies chest pain and palpitations

Respiratory: Denies shortness of breath or cough 

Gastrointestinal: Denies abdominal pain, nausea, vomiting, increased thirst, dry mouth 

Genitourinary: Any genital itching? Did you notice any abnormal vaginal discharge? Do you experience frequent urination? 

Integumentary: Denies rash, pruritus, thrush 

Breast: Any tenderness or discharge? 

Musculoskeletal: Denies myalgia, joint pain, back pain. 

Neurological: Denies headache, dizziness, weakness, syncope. 

Psychological:  Denies depression, anxiety, or suicidal thoughts. 

Describe the appropriate physical assessment that needs to be included in this visit.

Objective Data

VS:

BP is 118/78   P 68  RR 18   T 98.7 F

Fetal Heart Rate – 156

Weight 145 lbs – weight gain of 5 lbs in 4 weeks 

Height 5’5 

BMI – 24.1 

POCT:

1 hr gtt – 156 mg/DL.

Explain what test(s) you will order and perform, and discuss your rationale for ordering and performing each test

Urinalysis for presence of protein, glucose, ketones, WBC – negative 

General: A&O x 4, normal weight, no signs of acute distress, cooperative and answering questions appropriately 

Respiratory: Clear breath sounds to auscultation bilaterally, no use of accessory muscles, respirations within normal range 

Cardiovascular: Regular rate and rhythm, SI and S2 auscultated, no murmur, no JVD. 

Integumentary: No dark velvety patches in body folds and creases 

Genitourinary: NO pelvic exam. Gravid uterus, fundal height 25 cm corresponding with EGA, no adnexal tenderness. Auscultation of the fetal heart rate 

Psychological: Cooperative, appropriate mood and affect

Assessment/ Diagnosis

What is your diagnosis?

Gestational diabetes mellitus in pregnancy, diet controlled 
O24.410

This is presumptive diagnosis of GDM. According to Carpenter and Coustan Criteria, if one of the for measurement reading of 3 hr gtt is elevated, diagnosis is confirmed 

Include any appropriate differential diagnosis

Differential Diagnosis: 

Diabetic ketoacidosis 
E11.10 – UA negative for ketones, no s/s of hyperglycemia 

Down Syndrome 
Q90.9 – pt denied genetic screening 

Genetic syndromes that predispose an individual to impaired glucose tolerance  (Caughey, 2023)

Diabetes Mellitus 2 
E11.9 (undiagnosed )

Plan

Explain what test(s) you will order and perform, and discuss your rationale for ordering and performing each test.

Diagnostic tests

3‐hour oral glucose tolerance test 

The 3‐hour, 100 g OGTT is the common diagnostic test used in the United States when a 1‐hour screen is positive (Jordan et al., 2018).

HgA1C – to r/u overt diabetes rather than gestational diabetes with onset in pregnancy (Jordan et al., 2018). 

Ultrasound to assess fetal well being 

Treatment

If the patient fails her 3 hr gtt, what is the next course of action?

A patient will be diagnosed with GDM
 and initially treated with diet modification and physical activity, with monitoring of blood glucose levels. In this case patient will be considered to have 
A1 GDM with good glucose control  (Caughey, 2023)

If the patient passes her 3 hr gtt, what is the next course of action? Would you diagnose her as GDM?

Patient  would not be diagnosed with GDM. The next course of action would typically be to continue routine prenatal care, monitoring her blood sugar levels as part of standard pregnancy checks

Explain what medication regimen this patient could be on?

Patient may medication regimen to achieve glycemic control. In this case  patient will be considered to have 
A2 GDM in which glucose levels are medically managed with insulin or oral antihyperglycemic medications (Caughey, 2023)

The options for pregnant patients who require pharmacotherapy are insulin or certain oral antihyperglycemic medications (metformin or glyburide).

Insulin is the first line treatment because it is effective, easily adjusted based on glucose levels, safe for the fetus, and only FDA‐approved medication for women with GDM, whereas data are lacking regarding long-term outcomes for fetus exposed to oral antihyperglycemic medications in utero. That being said, oral antihyperglycemic medications are still a reasonable alternative to insulin for patients in whom pharmacotherapy is indicated but who decline to take, or are unable to comply with insulin therapy (Caughey, 2023)

The typical starting dose is 0.7–1.0 units/kg daily in divided doses.  A combination of intermediate‐acting NPH and fast‐acting insulin such as aspart or lispro is used together am and pm is most common (Jordan et al., 2018).

Referrals: Dietician or a certified diabetes educator for diet instruction. If GDM is not well controlled and complications arise, pregnancy becomes high risk and patient will be referred to a perinatologist. Clinical social workers, and licensed dieticians can become a part of healthcare team to assist with dietary adherance PRN 

What patient education is important to include for this patient?

Education:

· Overnight fasting for 8-19 hours before 3 hr gtt 

· Oral glucose used for gtt can cause nausea and vomiting

· Premedication with an antiemetic drug is acceptable in case of vomiting, patient needs to come back next day 

· Fetal growth and development, anticipated fetal movement

· Danger signs to report and how to contact provider

· Daily self‐monitoring of blood glucose of FBG and 1‐ to 2‐hour postprandial 

· At least 150 min/week of moderate‐intensity aerobic physical activity or at least 90 minutes/week of vigorous aerobic exercise 

· The physical activity should be distributed over at least 3 days/week and with no more than 2 consecutive days without physical activity

· Monitor carbohydrates

· Adhere to a dietary program of 2000–2500 kcal/day

· 33–40% complex carbohydrates, eliminating simple sugars, 20% protein, and 40% fats is a preferred diet

· Food is best taken in three meals with two to three snacks with carbohydrates evenly distributed throughout the day

· Availability of food services such as WIC and EBT SNAP if there is food insecurity

·  Moderate use of sweeteners is permitted

· Evening snack consisting of 15–30 g of carbohydrates an important part of nutrition therapy 

· The overnight fast should not exceed 10 hours

· Severe caloric or carbohydrate restriction should be avoided 

· Maintain normal pregnancy BMI of 18.5–24.9 with total weight gain of 25-35 lbs

                                                                                                               (Jordan et al., 201

Kristine

Hannah is 38 years old, G1P0, 32 weeks EGA, and comes to you for her routine prenatal appointment.  Her BP is 156/96, and her urine has 2+ protein.  She complains of having a headache that will not go away and just not feeling “right” for the past 7 days.

Case Scenario 1

Demographic Data

The patient is a 38-year-old Female

Subjective

Chief Complaint (CC):

A headache that does not feel “right” for the past 7 days

History of Present Illness (HPI):
 

The patient’s symptoms began 7 days ago; and she described it as constant and feeling unwell. The patient did not mention any relieving or aggravating factors that have helped her or made her situation worse. The headache has been present continuously for the last 7 days, and she indicates the headache is concerning her as it is affecting her overall well-being.

Review of Systems (ROS):

· General: reports headache for last 7 days. Denies fever, fatigue, fever, or weight loss.

· Cardiovascular: denies chest pain, SOB, dizziness

· Respiratory: denies SOB, coughing, or wheezing

· HEENT: reports headache for 7 days. denies vision changes, ear pain, or sore throat

· Musculoskeletal: denies joint pain, muscle weakness, and stiffness

· Neurological: reports headache for last 7 days. Denies numbness, tingling, or dizziness

· Genitourinary: Denies urgency, hematuria, or frequency

· Reproductive: reports G1P0, at 32 weeks

What other relevant questions should you ask regarding the HPI? 

· What were you doing when the pain started?

· Did you experience any vision changes? Any spots in your vision?

· Are you experiencing any nausea or vomiting with the headache?

· Did you experience any dizziness? Weakness?

· Have you experienced any swelling during your pregnancy?

What other medical history questions should you ask? 

· Have ever experienced this in the past?

· Do you have any history of hypertension? Before or during pregnancy?

· Have you ever been diagnosed with or experienced migraines?

· Are you currently taking any medications?

What other OB history questions should you ask?

· During your pregnancy, have you had any complications?

· Are you monitoring fetal movement? Noticed changes?

Allergies:

 NKDA

Objective

Vital Signs: WNL

T: 99.1 F

BP: 156/96 mmHg

Pulse: 91 bpm

RR: 18 breaths/min

Physical Examination:  

· General: AA&Ox3, appears in discomfort

· Cardiovascular: the patient’s heart rate and rhythm are normal. No murmurs or rubs auscultated. S1 and S2 heard.

· Respiratory: The chest wall is symmetrical, and nontender. Lung clear on auscultation bilaterally, unlabored breathing noted.

· HEENT: No sinus tenderness and ears are clear. Mucus membranes are pink, moist, and intact.

· Musculoskeletal: full ROM, no swelling

· Neurological: AA&Ox3, blood pressure 156/96

· Genitourinary: No visible discharge; urine protein is +2.

· Reproductive: currently at 32 weeks pregnant

· Psychiatric: no anxiety, depression, or psychiatric symptom