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Patient Information:
Initials: J.M., Age: 47, Sex: Female, Race: Hispanic
S.
CC
Patient Information:
Initials: J.M., Age: 47, Sex: Female, Race: Hispanic
S.
CC (chief complaint): “ Lower abdominal cramping and urinary leakage.”
HPI:
J.M. a 47-year-old Hispanic female came into the office with complaint of lower abdominal cramping and urinary incontinence for the past day. She also reports the suprapubic abdominal cramping that’s has increased in severity over the last several hours and describes the pain as sharp, intermittent, and becoming more frequent and painful. She states she has taken Motrin but received no relief. She rates the pain a 7/10.
Current Medications:
• Ibuprofen (Motrin) 200-400mg PO Q4-6hr for pain
Allergies:
• No known drug allergies
• No known food allergies
• No known environmental or seasonal allergies
PMHx:
• Menopause with onset approximately 8-12 months ago.
• Urinary tract infection approximately 1 year ago.
• The last gynecological examination took place several years ago.
• No surgical history.
• She is up to date with all childhood immunizations.
• Influenza vaccine 10/15/2023
• Covid series completed 2021.
• Tdap 09/08/2021
Soc & Substance Hx:
• J.M. is employed as a bank teller for the past 15 years. She enjoys reading and cooking new recipes. She has a great support system that includes her husband of 20 years and their 6 children. She denies tobacco, alcohol, vaping, and illicit drug usage. She wears her seatbelt when driving, denies cell phone usage while operating a vehicle, and has working smoke detectors in her home where she feels safe.
Fam Hx:
• Mother is deceased (MI) HTN, DMII
• Father is deceased (Prostate Cancer) HTN
• 6 children no medical history
• No other family history of cancer or blood disorders
Surgical Hx: No history of prior surgical procedures.
Mental Hx: No history of anxiety, depression, self-harm practices, suicidal or homicidal ideation
Violence Hx: Reports no concerns or issues with personal safety.
Reproductive Hx:
LMP 12/15/2022, G5 P5 LC 6, not currently lactating or nursing, reports participation in all types of intercourse ( oral, anal, and vaginal), does not use any type of birth control but practices NFP. Her gender sexual preference is men only (heterosexual).
ROS:
• GENERAL: Reports increased fatigue with no weight loss, fever or chills.
• HEENT: Denies nasal, throat, or dental problems. Denies nasal or sinus surgeries.
• CARDIOVASCULAR: Denies chest pain, chest pressure, palpitations, or edema. No history of heart murmurs.
• RESPIRATORY: Denies cough or shortness of breath.
• GASTROINTESTINAL: Reports abdominal cramping, increased flatulence, and constipation. No anorexia, nausea, vomiting, or diarrhea.
• NEUROLOGICAL: Denies headache, syncope, or dizziness.
• MUSCULOSKELETAL: Denies muscle pain, back pain, joint pain, or stiffness.
• HEMATOLOGIC: Denies anemia, bleeding, or bruising.
• PSYCHIATRIC: Denies depression or anxiety.
• ENDOCRINOLOGIC: Denies sweating, cold, or heat intolerance. No polyuria or polydipsia.
• GENITOURINARY/REPRODUCTIVE: Reports urinary incontinence and vaginal spotting several days ago. Denies burning on urination. Pregnancy. LMP: 12/15/2022. Denies breast-lumps and pain. Reports white and yellow nipple discharge. Reports of watery vaginal discharge with no pain. Reports she is sexually active with husband only.
• ALLERGIES: Denies allergies to food, drugs, seasonal, and environmental allergens.
O.
Physical exam:
• V/S—T:99.1, BP 140/82, P:88, RR:15, Height:5’0, Weight: 235, BMI:45.89
• General: J.M. is a 47-year-old Hispanic female, who is alert and oriented and able to make needs known. She is sitting upright on the examination table. Appears to be stated age, is well developed, well nourished, well-groomed, and has good hygiene. She is obese, cooperative, and a good historian. She answers all questions appropriately.
• HEENT: Nares patent bilaterally, throat without erythema or exudate, buccal mucosa pink and moist with no lesions, teeth are in good repair with no loose teeth.
• Skin: Intact with good turgor and no lesions noted.
• Cardiovascular: S1/S2 noted, no murmurs, gallops, or rubs, RRR.
• Respiratory: Lungs clear to auscultation, regular respiratory rate, with symmetrical diaphragmatic excursion. No CVA tenderness.
• Abdomen: Mass detected in abdomen, not fully assessable because of body habitus, otherwise soft and non-tender. BSx4. No guarding or rebounding noted. Fungal dermatitis noted under pannus.
• Genitourinary/Rectal: Breast pendulous, bilateral white and yellow nipple discharge note. VVBSU WNL, some watery discharge noted, and nitrazine positive. Vagina pink with rugae present, Good pelvic support, no cystocele or rectocele noted. Cervix soft, smooth, without CMT. OS parous, and slightly open. The uterus is difficult to assess due to body habitus, however, feels enlarged by bi manual exam. Adnexa not palpated.
Diagnostic results:
• CMP,CBC, TSH, T3, T4, ESR, HGB A1C, VIT D HYDROXY, Total cholesterol, HDL, LDL, AST, ALT, Hep C, GFR, BUN, CRE, HCG
• Urine Dipstick: SG 1.010, trace blood, negative nitrates, negative leukocytes, negative glucose, 3+ protein.
• Urine Culture: The patient has a history of urinary tract infections.
• Ultrasound or CT of abdomen ( according to the Urine Pregnancy Test results) because of inability to fully assess mass in abdomen.
• HCG Pregnancy test because patient had recent spotting and assumes she is in early menopause.
A.
1. Pregnancy: The patient stated that she has not had a menstrual period in approximately 8- 12 months and suspects she has gone through menopause because of this change in her menstrual periods. “It is well documented that maternal and fetal complications occur more frequently with advanced maternal age. Furthermore, maternal co-morbidities such as hypertension or diabetes are also more common due to the age-dependent onset of these diseases. Moreover, cesarean section rates for pregnancies in this age group are higher, as are the prevalence of gestational diabetes, hypertension, decreased fetal birth weight, preterm delivery, and stillbirths” (Rendtorff et al., 2019)
2. Preeclampsia: “Hypertensive disorders of pregnancy affect 10% of pregnancies and are defined by the International Society for the Study of Hypertension in Pregnancy (ISSHP) as new onset hypertension (≥140 mmHg systolic or ≥90 mmHg diastolic) after 20 weeks’ gestation. This umbrella definition includes chronic hypertension, gestational hypertension, and preeclampsia (de novo or superimposed on chronic hypertension). Both conditions can have significant impacts on maternal and fetal health in the immediate and long term.” (Fox et al., 2019)
3. Oligohydramnios: “Oligohydramnios is defined as decreased amniotic fluid volume (AFV) for gestational age. The volume of amniotic fluid changes over gestation, increasing linearly until 34 to 36 weeks gestation, at which point the AFV levels off (approximately 400mL) and remains constant until term. The AFV then begins to decrease steadily after 40 weeks gestation, leading to reduced volume in post-term gestations. This pattern allows for clinical assessment of AFV throughout pregnancy using fundal height measurements and ultrasound evaluation.” (Keilman et al., 2022)
4. Urinary Incontinence: “Urinary incontinence is a common condition in women worldwide, which can be distressing both physically and mentally and burdensome to the individual and society. Many women may first experience urinary incontinence during pregnancy. Physiological changes during pregnancy such as increased abdominal pressures and progesterone levels and injury to the pelvic floor may make women more susceptible to urinary incontinence. As a result, more than half of women suffered from urinary incontinence during pregnancy and peaked in the third trimester.” (Wang et al., 2022)
5. Obesity: “Older women are at greater risk of suffering from a series of comorbidities such as obesity, diabetes, and hypertension that could negatively affect pregnancy course and outcomes.” (Bapayeva et al., 2022)
6. Candida albicans (fungal dermatitis under pannus): “Candida albicans is a common commensal fungus that colonizes the oropharyngeal cavity, gastrointestinal and vaginal tract, and healthy individuals’ skin. In 50% of the population, C. albicans is part of the normal flora of the microbiota. The various clinical manifestations of Candida species range from localized, superficial mucocutaneous disorders to invasive diseases that involve multiple organ systems and are life-threatening. From systemic and local to hereditary and environmental, diverse factors lead to disturbances in Candida’s normal homeostasis, resulting in a transition from normal flora to pathogenic and opportunistic infections.” (Talapko et al., 2021)
P.
• Pregnancy- Pelvic examination, urine and blood HCG, ultrasound of abdomen, and preparation for possible labor and delivery.
• Preeclampsia-antihypertensive medications and antiseizure medications (magnesium sulfate)
• Candida Albicans (fungal dermatitis)- Nystatin plied to affected area until healing has occurred or as indicated.
• Obesity- encourage loss of weight, healthy eating habits, and a increase in activity as tolerated.
• Oligohydramnios: Complete a pelvic examination and nitrate paper test for evidence of amniotic fluid leakage. (test completed and positive)
• Education:
o Encourage the patient to maintain regular doctor’s visits for health maintenance.
o Encourage weight loss and diet changes.
o Educate the patient on all aspects of the medication prescribed and the importance of taking it as prescribed and completion of the medication.
o Educate the patient on signs and symptoms of menopause and the possibility of pregnancy when using the NFP method versus a manual contraception.
o If the patient is not pregnant, the patient should be prescribed antihypertensives for high blood pressure maintenance.
• Referred to Gynecology and obstetrics’.
• Follow-up in 8 weeks with PCP.
References
Bapayeva, G., Terzic, S., Dotlic, J., Togyzbayeva, K., Bugibaeva, U., Mustafinova, M., Alisheva, A., Karaman, E., Terzic, M., & Laganà, A. S. (2022). The Influence of Advanced Age and Obesity on Pregnancy Course and Outcome in Patients with Diabetes Mellitus. Przeglad menopauzalny = Menopause review, 21(3), 170–179. https://doi.org/10.5114/pm.2022.116351
Fox, R., Kitt, J., Leeson, P., Aye, C. Y. L., & Lewandowski, A. J. (2019). Preeclampsia: Risk Factors, Diagnosis, Management, and the Cardiovascular Impact on the Offspring. Journal of clinical medicine, 8(10), 1625. https://doi.org/10.3390/jcm8101625
Keilman, C., & Shanks, A. L. (2022). Oligohydramnios. In StatPearls. StatPearls Publishing.
Rendtorff, R., Hinkson, L., Kiver, V., Dröge, L. A., & Henrich, W. (2019). Pregnancies in Women Aged 45 Years and Older – A 10-Year Retrospective Analysis in Berlin. Geburtshilfe und Frauenheilkunde, 77(3), 268–275. https://doi.org/10.1055/s-0043-100105
Talapko, J., Juzbašić, M., Matijević, T., Pustijanac, E., Bekić, S., Kotris, I., & Škrlec, I. (2021). Candida albicans-The Virulence Factors and Clinical Manifestations of Infection. Journal of fungi (Basel, Switzerland), 7(2), 79. https://doi.org/10.3390/jof7020079
Wang, X., Jin, Y., Xu, P., & Feng, S. (2022). Urinary Incontinence in Pregnant Women and its Impact on Health-Related Quality of Life. Health And Quality of Life Outcomes, 20(1), 13. https://doi.org/10.1186/s12955-022-01920-2
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