Case Scenario 1

Table 1
Standard level of HCG during pregnancy.
GA weeks HCG level
Three weeks LMP 5 – 50 mIU/ml
Four weeks LMP 5 – 426 mIU/ml
Five weeks LMP 18 – 7,340 mIU/ml
Six weeks LMP 1,080 – 56,500 mIU/ml
7-8 weeks LMP 7,650 – 229,000 mIU/ml
9-12 weeks LMP 25,700 – 288,000 mIU/ml
13-16 weeks LMP 13,300 – 254,000 mIU/ml
17-24 weeks LMP 4,060 – 165,400 mIU/ml
25-40 weeks LMP 3,640 – 117,000 mIU/ml
Nonpregnant 55 – 200 ng/ml

Table 2
Scenario
In a normal ongoing pregnancy, the expectation for the beta HCG
level is to __double___ (hint: increase by how much) within 48-72
hours
During a spontaneous abortion (miscarriage), the expectation for
the beta HCG level is to _decrease by 21% to 35%___ (hint:
decrease by how much) within 48-72 hours.
During an ectopic pregnancy, the beta HCG level is expected to
plateau or increase by 50%__ within 48-72 hours.
During a gestational trophoblastic pregnancy, the beta HCG level is
expected to be exceptionally higher than normal levels of HCG_
within 48-72 hours.

Table 3
Common complaints during pregnancy.
Remember that these symptoms are during pregnancy; make sure the cause, presentation, and
treatment are related to the pregnancy status of the patient.

Definition and Presentation Treatment Education

Cause (include
possible DDX)
Constipation Having less Less than three Use of OCT Patients should
than three movements of laxatives such as be educated not
movements of bowel in a magnesium to skip meals.
bowel in a week, painful citrate and stool They are
week. It results stools that are softeners. Other encouraged to
from slow stool difficult to pass, include increase high-
or waste lumpy, hard, exercising and fiber foods'
 movement and dry stools, drinking more quantity in their
through the and decreased water. diet.
digestive tract appetite.
with ineffective
elimination
from the
rectum. It is
caused by
ignoring the
urge for bowel
movement,
medications,
intestinal
function
problems, not
taking enough
liquids, and
changes in
lifestyle.
Back pain It is discomfort Difficult Taking pain Educate the
occurring at the bending, relievers, patient on self-
back or spine lessened back including management
and can be pain with naproxen, strategies such
disabling or activity, pain ibuprofen, and as exercise and
mild. It is radiating away paracetamol. avoiding
caused by heavy to hip, buttocks, prolonged
lifting, age- or leg, and sitting periods.
related increasing pain
degenerative with lifting
changes, falls, heavy loads.
and accidents.
GERD It is a condition Chest pain, Antacid, Educate the
resulting from hoarseness or antidiarrhoeal, patient to avoid
stomach chronic cough, and proton-pump peppermint,
contents' nausea, pain inhibitor. caffeine, and
movement to while chocolate.
the esophagus. swallowing. Avoid oranges,
It is caused by spicy foods, and
reflux of non- juice, which
acid content may also result
from the in symptoms.
stomach and
frequent acid
reflux.
Fatigue It is an extreme Lack of energy, Nortriptyline, Encourage the
tiredness caused sleepiness, fluoxetine, and patient to eat a
 by physical muscle pain, sertraline. healthy diet and
illness or mental and chronic to have plenty
exhaustion. It is tiredness. of rest. Educate
caused by the patient to
having too little reduce the use
or too much of alcohol,
physical caffeine, and
activity, eating tobacco.
poorly, drug
use, and
inadequate
sleep.
Heart palpitations It is the feeling Irregular Calcium channel Encourage the
of pounding or beating of the blockers or beta- patient to
fluttering and heart and blockers. reduce stress,
fast beating. It pounding exercise, and
is caused by sensation in the engage in yoga.
depression, neck or chest. Educate them to
strong avoid alcohol
emotional and caffeine.
response, and
hormone
changes.
Urinary frequency It is abnormal Difficult to Tolterodine and The patient
urination control urine, oxybutynin (Chu should be
frequency, for sudden urge to & Lowder, educated to
example, once urinate, and 2018). avoid taking
or twice per urinating drinks before
hour. Diabetes frequently. going to bed.
insipidus,
diuretics, and
anterior vaginal
prolapse cause
it.
Nausea and Vomiting Choking, Benzodiazepines Avoid spicy,
Vomiting involves mouth-filling , lorazepam, and salty, or fatty
throwing with saliva, Ativan. foods.
contents out of gagging, and
the mouth and involuntary
up through the stomach
esophagus from reflexes.
the stomach.
Nausea is the
urge to vomit. It
is caused by
overeating high-
 fat or spicy
foods.
Round ligament It is a Shooting pain Acetaminophen. Encourage
pain discomfort of around the resting and
the pregnancy growing belly, wearing a
or pain related increased pain pregnancy
to the uterus’s during support belt.
round ligament. sneezing,
It is caused by coughing, or
standing up laughing, and
quickly, stabbing pain
walking, and on the right side
rolling over the of the pelvis.
bed.
Hyperpigmentation It is a skin Pink spots or Retinoids, Advise the
condition red, brown, including patients to use
involving skin black, or gray adapalene and skin acids and
patches darker patches. Others tretinoin. retinoids to
than the include skin reduce the
surrounding peeling and appearance.
skin. Freckles, itching.
injury, melisma,
and
inflammation
cause it.
Sleep disturbance The changes in Trouble staying Antidepressants Advise
sleep habits or asleep at night, and stimulants. individuals
patterns affect snoring, affected to
an individual's choking during create a clean,
health sleep, and comfortable,
negatively. It is difficulty and quiet place
caused by falling asleep. for sleeping.
working the
night shift,
medication, and
mental health
conditions like
anxiety
disorder.

Tonia is an 18-year-old female who presents to your office complaining of two months of
amenorrhea. Her pregnancy test is positive, and her LMP indicates she is 5.6 weeks EGA. She
reports she has had some bleeding for the past three days that started as spotting but has
continued to be a light period-like bleeding today. She denies any pain. She indicates plans to
continue the pregnancy.
1. Subjective:
a. What other relevant questions should you ask regarding the HPI?
 Have you been pregnant in the past?
 What is the color of the blood from your bleeding?
b. What other medical history questions should you ask?
 Do you have any history of miscarriage?
 Do you have a history of vaginal infection or STIs?
c. What other social history questions should you ask?
 Are you married?
 Is your relationship safe?
2. Objective:
a. Describe all elements of the head-to-toe assessment you will perform for her initial
prenatal visit.
 General: Well-nourished and no acute distress.
 HEENT: She denies vomiting, headache, and nausea.
 Cardiovascular: No murmur or palpitations.
 Respiratory: Denies shortness of breath and coughing.
 GI: Positive bowel sounds, soft, non-distended, and no palpable masses.
 Musculoskeletal: Denies joint pain and myalgia.
 GU: denies pain, dysuria, and frequency. Reports period-like bleeding.
 Genital: No discharge, even hair distribution, and no noted masses or lesions.
 Neurological: Denies tingling nu, numbness, and weakness.
b. Explain what test(s) you will order and perform, and discuss your rationale for ordering
and performing each test.
 The tests I will order include HCG level, blood type to ensure the rhesus factor match and
safety of the pregnancy, CBC test to determine the red blood cells ratio, and transabdominal and
transvaginal ultrasound to confirm the pregnancy viability.
3. Assessment/ Diagnosis:
a. What are your presumptive and differential diagnoses, and why?
 Leiomyoma of the uterus and bleeding in early pregnancy. This is because of the light
period-like bleeding (Parker et al., 2022).
b. Is there any other diagnosis or differential diagnosis you would like to add?
 Hydatidiform mole and spontaneous abortion.
c. Assume you ordered an HCG today, and the result was 1200. She returns to the clinic in 2
days, and her HCG result is 550. What would be her diagnosis?
 Non-viable intrauterine pregnancy or ectopic.
4. Plan:
a. How will you explain the HCG results to your patient?
 The high HCG level is an indication of pregnancy. When the qualitative HCG test shows
negative results, it indicates no pregnancy. False positive results may be obtained if the hormone
levels are high because of hormone supplements.
b. Explain treatment guidelines and side effects, including any possible side effects of the
medication and treatment(s), partner notification, and follow-up care plan.
 Follow the prescription instructions for the misoprostol with an intravaginal dose. The
side effects of misoprostol include nausea, diarrhea, and stomach cramps. Inform the partner
about the bleeding and request screening to find out about the baby's safety. Follow up after two
to three days to find out if the prescribed drugs are working or not relieving the symptoms.
c. What patient education is important to include for this patient? (Consider when the
patient can resume sexual activity, birth control options, and when she can resume trying to
conceive again). Provide evidence from the research to support your decision-making.
 The patient should be educated to wait two weeks after the pregnancy loss without
engaging in sexual activity. The patient should be informed that after six weeks, menses resume,
and she can conceive again if and so, birth control would be essential.

References
Chu, C. M., & Lowder, J. L. (2018). Diagnosis and treatment of urinary tract infections across
age groups. American journal of obstetrics and gynecology, 219(1), 40-51.
Parker, M., Hannah, M., & Zia, A. (2022). “If I wasn't a girl”: Experiences of adolescent girls
with heavy menstrual bleeding and inherited bleeding disorders. Research and Practice
in Thrombosis and Haemostasis, 6(4), e12727.