NU576 Unit 7 Journal

Student Name

Purdue University Globle 

NU576 NP II – Primary Care of Women’s Health

Prof. Name

Date

NU576 Unit 7 Journal

During a normal second-trimester pregnancy, prenatal care focuses on monitoring maternal and fetal health, managing common symptoms such as lower back pain, completing recommended prenatal screenings, and addressing risk factors that may affect pregnancy outcomes. In this case, a 35-year-old pregnant patient relocating from Ohio requires continued prenatal monitoring, assessment of pregnancy-related discomfort, counseling regarding alcohol use during pregnancy, and ongoing evaluation for perinatal depression due to a significant mental health history.

Overview of the Patient Encounter

Lara Taylor, a 35-year-old woman at 20 weeks’ gestation, presented to establish prenatal care after relocating from Ohio. She reported experiencing mild lower back pain associated with pregnancy but denied other significant concerns. Her clinical presentation is consistent with a normal second-trimester pregnancy; however, several factors warrant additional attention, including advanced maternal age, prior pregnancy losses, a history of depression, and ongoing alcohol consumption during pregnancy.

Patient Information

• Patient Name: Lara Taylor

• Encounter Number: 5466525

• Date of Visit: October 10, 2023

• Age: 35 years

• Sex: Female

• Gestational Age: 20 Weeks

Chief Complaint

The patient stated:

“I’m here to establish prenatal care. I just moved here from Ohio.”

History of Present Illness

Lara Taylor is a 35-year-old gravida 3 patient presenting at 20 weeks of pregnancy for the establishment of prenatal care. She recently relocated from Ohio and seeks continuity of prenatal services.

Her primary complaint is lower back pain, which she describes as a “tugging” sensation. The discomfort worsens after prolonged standing and improves with rest, suggesting musculoskeletal strain associated with pregnancy-related postural changes and increasing uterine size.

Her obstetric history includes:

• One previous abortion

• One miscarriage

• Current third pregnancy

The patient currently takes over-the-counter prenatal vitamins and reports discontinuing Lexapro several years ago after previous episodes of pregnancy-related depression.

Allergies and Medical History

Allergies

• Latex (causes rash)

Past Medical History

The patient reports:

• Two prior episodes of depression associated with pregnancy

• No chronic illnesses

• No history of major trauma

Surgical History

• Dilation and curettage (D&C) performed five years ago

Family History

The patient’s family history includes several notable health conditions:

• Father deceased at age 60 due to myocardial infarction.

• Mother living with type 2 diabetes mellitus for approximately 10 years.

• Brother without known medical concerns.

Social History

The patient holds a university degree and teaching certification and currently works as a substitute teacher.

She married three months ago and lives with her husband, who is currently unemployed following their move.

Significant social factors include:

• Former smoker (previously one pack per day; quit after learning of pregnancy)

• Reports consuming one glass of wine nightly

• Denies current illicit drug use

• History of marijuana use and hemp gummy consumption

The patient’s alcohol intake during pregnancy is a notable concern, as prenatal alcohol exposure is associated with adverse fetal outcomes, including fetal alcohol spectrum disorders.

Review of Systems

General

The patient reports:

• Weight gain from 155 pounds to 167 pounds

• Increased fatigue

Cardiovascular

The patient denies:

• Chest pain

• Palpitations

Respiratory

The patient denies:

• Cough

• Congestion

• Shortness of breath

Gastrointestinal

The patient denies nausea, vomiting, diarrhea, and abdominal pain but reports constipation since becoming pregnant.

Genitourinary

The patient reports:

• Increased urinary frequency

• Sexual activity with her husband

She denies dysuria and urinary discomfort.

Musculoskeletal

The patient reports lower back pain associated with pregnancy-related physical changes.

Breast

The patient reports increased breast size and denies:

• Breast pain

• Nipple discharge

• Breast masses

Neurological

The patient denies:

• Weakness

• Dizziness

• Seizures

Psychiatric

The patient has a history of pregnancy-related depression. During the visit, she avoided eye contact and appeared uncomfortable when discussing her husband, indicating the need for further assessment of emotional well-being, social support, and potential psychosocial stressors.

Objective Assessment

Vital Signs

• Weight: 167 pounds

• Height: 5 feet 2 inches

• BMI: 30.5 kg/m²

• Temperature: 98°F

• Blood Pressure: 132/64 mmHg

• Pulse: 75 beats/minute

• Respiratory Rate: 20 breaths/minute

Physical Examination Findings

General Appearance

The patient appeared healthy, cooperative, and appropriately responsive throughout the examination.

HEENT

• Normocephalic and atraumatic head

• Pupils equal, round, reactive to light and accommodation

• Patent ear canals and nares

• Teeth intact without evidence of dental caries

Cardiovascular

• Regular rate and rhythm

• Normal S1 and S2

• No murmurs

• No peripheral edema

Respiratory

• Clear bilateral breath sounds

• Symmetrical chest expansion

• Unlabored respirations

Gastrointestinal

Examination revealed a gravid abdomen with active bowel sounds in all quadrants and no tenderness.

Genitourinary

Pelvic examination findings included:

• Normal vulva

• No lesions or masses

• Normal vaginal canal

• Cervix without lesions or discharge

• Anteverted, nontender uterus

• No hemorrhoids identified

Musculoskeletal

• Full range of motion in all extremities

• No significant tenderness or stiffness

Neurological

• Clear speech

• Steady gait

• Appropriate posture

Psychiatric

The patient was alert and oriented to person, place, and time. Although speech and behavior were appropriate, her prior history of depression and observed affect support additional mental health evaluation during prenatal follow-up.

Recommended Prenatal Laboratory and Diagnostic Testing

Appropriate prenatal testing during the second trimester includes:

• Complete blood count (CBC)

• Blood type and Rh factor

• Hepatitis B screening

• Syphilis screening

• HIV testing

• Glucose screening for gestational diabetes

• Ultrasound evaluation for fetal growth and anatomy assessment

These screenings help identify conditions that may influence maternal and fetal outcomes and are considered essential components of comprehensive prenatal care.

Assessment

Primary Diagnosis: Normal Second-Trimester Pregnancy (13–26 Weeks)

The patient’s presentation is most consistent with a healthy second-trimester pregnancy accompanied by common physiological changes, including:

• Weight gain

• Fatigue

• Urinary frequency

• Breast enlargement

• Constipation

• Mild lower back pain

Her back discomfort is likely secondary to increased abdominal weight, ligament stretching, and pregnancy-related postural changes.

Differential Diagnoses

Miscarriage

Miscarriage is defined as pregnancy loss before 20 weeks’ gestation and may present with:

• Vaginal bleeding

• Abdominal cramping

• Passage of tissue

Although the patient has a history of miscarriage, she currently exhibits no signs or symptoms suggestive of pregnancy loss.

Molar Pregnancy

A molar pregnancy is characterized by abnormal placental tissue development rather than a viable fetus. Typical manifestations may include abnormal uterine enlargement, elevated human chorionic gonadotropin (hCG) levels, and vaginal bleeding.

Current clinical findings do not support this diagnosis.

Plan of Care

Medication Recommendations

Medication use during pregnancy should be individualized and provider-directed. Potential options include:

• Acetaminophen (Tylenol) for pain relief

• Docusate sodium (Colace) for constipation

• Famotidine (Pepcid) for reflux symptoms when indicated

Additional medications should only be used after clinical evaluation to ensure maternal and fetal safety.

Non-Pharmacological Interventions

To improve comfort during pregnancy, the patient should be encouraged to:

• Stay physically active as tolerated.

• Avoid prolonged standing.

• Practice proper body mechanics.

• Incorporate pregnancy-safe stretching exercises.

• Rest when symptoms worsen.

Patient Education

Prenatal counseling should emphasize:

• Complete avoidance of alcohol during pregnancy.

• Continued use of prenatal vitamins.

• Attendance at all scheduled prenatal appointments.

• Recognition of warning signs, including:

  • Vaginal bleeding

  • Severe abdominal pain

  • Persistent headaches

  • Visual disturbances

  • Reduced fetal movement later in pregnancy

Mental Health Considerations

Perinatal depression screening should be incorporated into routine prenatal visits. Given her history of depression and observed emotional discomfort during the examination, additional evaluation using validated screening tools, such as the Edinburgh Postnatal Depression Scale (EPDS), is recommended.

Early identification and intervention can improve maternal mental health outcomes and promote healthier pregnancies.

Health Promotion Strategies

Key preventive measures for this patient include:

• Routine prenatal follow-up visits

• Nutritional counseling

• Gestational diabetes screening

• Infection screening

• Mental health monitoring

• Smoking and alcohol cessation counseling

Referrals

Referral to an obstetrician/gynecologist (OB/GYN) is recommended for ongoing prenatal management and coordination of care throughout the remainder of the pregnancy.

Follow-Up Recommendations

The patient should return in approximately four weeks for continued prenatal monitoring or sooner if she develops concerning symptoms, including vaginal bleeding, severe pain, headaches, or changes in fetal movement.

References

Allo Health. (2023, July 15). Differential diagnosis of pregnancy: A comprehensive guide. https://www.allohealth.care/healthfeed/pregnancy/differential-diagnosis-of-pregnancy

Cleveland Clinic. (2018, January). Medicine guidelines during pregnancy. https://my.clevelandclinic.org/health/drugs/4396-medicine-guidelines-during-pregnancy

NU576 Unit 7 Journal

Johns Hopkins Medicine. (2021, August 8). The second trimester. https://www.hopkinsmedicine.org/health/wellness-and-prevention/the-second-trimester

Nguyen, T. (2022, July). Prenatal tests: Second trimester. KidsHealth. https://kidshealth.org/en/parents/tests-second-trimester.html