STUDENT PROBLEM-BASED LEARNING SESSION
Clinical Problem Basis:
Immediately upon completion of your residency in Obstetrics and Gynecology you are employed by a Suburban Branch of the County Health Department. Though technically suburban, this area is part of a larger urban community and has a significant indigent and uninsured population. As part of your new job you will be:
She is a 28 year old Hispanic gravida 3, para 1101 whose last menstrual period was 24 weeks ago. She has had no contact with any health care provider prior to you. Since she has been aware of her pregnancy, she has felt tired, noticed increased pelvic pressure, had heavy vaginal discharge and experienced nausea with vomiting 3 to 4 times per week.
She has never been hospitalized except for the delivery of her two previous pregnancies. As a child she experienced frequent coughs.
Her first pregnancy was two years ago. She began prenatal care in Mexico in the "third month". In the last month of her pregnancy, she presented to the emergency room with headaches and swelling. She states that she was "toxic" and that the baby had died because it was too small. She was given a medicine that made her hot and another that made her have "hard labor". She states she started to bleed and then delivered the baby right away. It was a stillborn baby boy weighing 1580 grams with creases on the infant's sole all the way to the heel.
Her second pregnancy was delivered 12 months ago. She became pregnant as soon as her periods returned, on the advice of her family. She felt fine and was planning to go back to the doctors who delivered her first baby. She experienced a blood tinged discharge at approximately 27 weeks and went to the emergency room. She was told she was dilated and if she stood up the water bag would fall out. She was admitted to the hospital and given the medicine that made her hot again. She says two days later they stopped the "hot" medicine and gave her pills that made her heart pound. She described rupture of the membranes three days later. One week later she developed chills, fever and labor pains. The same day she delivered a 1100 gram female infant by cesarean section ("the baby was coming backwards"). The baby remained hospitalized for 3 months but is now at home and reportedly doing well.
The patient does not smoke. She drinks 3 beers after work each day. She is employed cleaning houses and works as needed by a service run out of her boss's house. She smokes marijuana when the baby's father brings it home.
Physical exam: Height 5'2", weight 101 pounds, blood pressure 120/80, P 99, R 18, T 99.0.
The APGO Educational Objectives related to this topic are the following: