Sample Nursing Case Studies

Tara is a 32yo, G3 P2002, who is currently 22 weeks 2 days. She follows in the High Risk Obstetrical Clinic secondary to a history of chronic HTN. She also has a history of preeclampsia in both her prior pregnancies. She reports that her high BP developed in her 1st pregnancy. Around 2 years later she had a stroke that she reportedly thinks was related to uncontrolled HTN. There has been some question in her history about a thrombophilia specifically factor V Leiden, although we do have a negative mutation test in our records as well as a negative test for lupus anticoagulant, anticardiolipin, and B2 glycoprotein. There was at least one positive lupus anticoagulant test one month prior to her negative one. Also, in her last pregnancy she had a notable postpartum hemorrhage secondary to a retained placenta. She lost over 2000 cc. She was intubated in her prior uterine artery embolization to control bleeding.
At today’s office visit she complains of rectal bleeding.
She reports this to be cherry, lumpy clots that are noted both when using the restroom and the toilet as well as in her underwear. She has known hemorrhoids but does not feel like this is bleeding from hemorrhoids as she does not have any current pain. This has started since she restarted the Plavix 3 weeks ago. She does, however, have a history of rectal bleeding in/outside of pregnancy and off/on Plavix. She has had 2 colonoscopies previously. The most being with a GI physician in Sweetwater about 2-3 years ago. Both were reportedly negative. She was admitted to Blount Memorial Hospital with rectal bleeding several years ago when the 1st colonoscopy was performed. She has never received a diagnosis as to why she has bleeding. Finally, at her last scan we were unable to complete the anatomic survey and she is here today to complete the fetal anatomical
survey.

On ultrasound, there is a live fetus in cephalic presentation. Fetal biometry is consistent with dates. A limited survey including profile and cardiac views was unremarkable. Amniotic fluid appeared normal as well. The placenta is anterior but not low-lying.

I had a long discussion with Tara at today’s office visit regarding her rectal bleeding. I elicited the history above. I also discussed in detail her CVA as well as the potential risk for clots. According to the notes in our office it was previously decided that she would be on low-dose aspirin. At some point, someone has asked her to restart Plavix and I will look into this through the High Risk Obstetrical Clinic. For now, I took her off of the Plavix and placed her back on low-dose aspirin in hopes that this will stop the rectal bleeding that is concerning to her; however, we will need to establish an actual diagnosis for the bleeding but doing this in pregnancy seems quite difficult as we are limited with GI procedures. We also discussed her significant heartburn with decreased appetite. She currently is on pantoprazole and I did add Zantac to that. I explained that this is not ideal, although with significant heartburn she has no desire to eat. Ultimately, if this does not improve perhaps we can try the Reglan. For now, she is scheduled to return in 2 weeks to evaluate rectal bleeding.

Thank you for referring this patient to our office. Please do not hesitate to call us if you have any questions.

THIS REPORT HAS BEEN DICTATED BUT NOT EDITED
Lynlee Wolfe, M.D.
Maternal-Fetal Medicine