A 20 year-old G1P0A0 female presents to your clinic complaining of crampy lower abdominal pain and spotting. She states her last period was 5 weeks ago, she took a home pregnancy test yesterday and it was positive. She states she tried to make an OB appointment but they could not get her in for several weeks. What questions would you ask this patient? Describe how you would assess and treat this patient using evidence-based practice. Submissions should be in APA format and should include an introduction/conclusion.

Introduction

When assessing a patient presenting with crampy lower abdominal pain and spotting, it is important to gather relevant information to better understand the patient’s condition and provide appropriate care. This paper outlines the questions to ask during the patient interview and discusses the assessment and evidence-based treatment strategies for this 20-year-old G1P0A0 female.

Questions for the Patient

To gather a comprehensive medical history, it is essential to ask specific questions related to the patient’s presenting complaints, pregnancy, menstrual history, and other relevant factors. The following questions are recommended for this patient:

1. Can you describe the characteristics of the lower abdominal pain?
This question helps evaluate the nature, severity, and location of the pain and assists in diagnosing possible causes.

2. When did the pain start? Has it changed since then?
Understanding the onset and course of the pain provides valuable insights into its potential cause and severity.

3. Can you describe the amount and color of the spotting?
Determining the quantity and characteristics of the vaginal bleeding aids in differentiating between potential causes, such as implantation bleeding or a miscarriage.

4. How regular are your menstrual cycles?
Obtaining information about the patient’s menstrual history allows for an assessment of potential pregnancy-related complications, such as an ectopic pregnancy.

5. Have you experienced any previous pregnancies or terminations?
Knowledge about the patient’s obstetric history provides valuable information about her reproductive health and potential risk factors.

6. Have you had any additional symptoms, such as nausea or breast changes?
Identifying associated symptoms helps in assessing the patient’s overall well-being and determining the potential cause of her symptoms.

7. Have you taken any medications or undergone any recent procedures?
Understanding the patient’s medication history and previous procedures helps identify potential pregnancy-related risks or complications.

Assessment

To assess this patient, a thorough physical examination is necessary. Perform a complete pelvic examination to assess the cervix, uterus, and adnexa. Additionally, a transvaginal ultrasound can be used to evaluate the uterus and ovaries and confirm the presence of an intrauterine pregnancy. Laboratory tests, such as a quantitative hCG test and a complete blood count, can provide additional information about the patient’s condition.

Treatment using Evidence-Based Practice

The treatment for this patient will depend on the findings of the assessment, as well as her preferences and individual circumstances. However, evidence-based practice guidelines can help inform the decision-making process. The following treatment considerations can be made based on current evidence:

1. Obstetric referral: Given the patient’s positive pregnancy test and symptoms, an expedited referral to an obstetrician or a specialist in early pregnancy care is warranted. It is crucial to ensure appropriate prenatal care to monitor the progression of the pregnancy and assess for potential complications.

2. Counseling and support: This patient may be experiencing anxiety and uncertainty due to the delay in obtaining an obstetric appointment. Providing emotional support and counseling on the importance of prenatal care can alleviate her concerns and promote a positive pregnancy experience.

3. Pain management: If the patient’s abdominal pain is severe, appropriate pain management strategies can be employed. Nonsteroidal anti-inflammatory drugs (NSAIDs) should generally be avoided during pregnancy, but acetaminophen can be used to relieve pain and discomfort. However, it is important to consider any contraindications or potential adverse effects before administering any medication.

4. Monitoring for complications: Given the patient’s spotting and abdominal pain, close monitoring for potential complications, such as ectopic pregnancy or threatened miscarriage, is crucial. Serial measurements of hCG levels and continued assessment of symptoms and physical findings are essential to identify any concerning developments.

In conclusion, thorough assessment and evidence-based practice are essential when managing a patient presenting with crampy lower abdominal pain and spotting, especially when a positive pregnancy test is involved. By asking relevant questions and conducting a comprehensive assessment, healthcare providers can provide appropriate treatment and ensure optimal care for the patient.