SUBJECTIVE: 35-year-old female; eager to get a child, never tried being pregnant before due to her nature of work at a Law firm. The patient is sexually active, with a partner for two years. Partner is impatient with the absence of a child in the relationship, and the patient fears to lose her partner despite the assurance that the relationship is monogamous, which she hopes is the case, but she is anxious due to the timeframe remaining. Patient fears being categorized as an elderly primigravida. The patient seeks medical assistance to get pregnant, I am afraid of losing my husband to another woman, please assist me in getting pregnant. Patient has been using contraceptives for the last ten years and having unprotected sex with the partner.
PMH: Patient obese, otherwise overall unremarkable; no serious ailments history over the previous five years. Patient has primary hypertension and under medication. Surgeries; several due to a road accident in the past; otherwise non-contributory. Heavy and irregular menstrual cycles lasting longer than usual. Pain during sex a common occurrence and at times bleeding. No history of polycystic ovarian syndrome or STIs. Previous accidents and hospitalizations: Two accidents in the past five years but never affected the reproductive organs; otherwise non-contributory
FH: One sister with twins and a brother with triplets; otherwise non-contributory
SH: Patient is a professional lawyer managing her Law firm. Smoker, alcoholic, and the family life is remarkable and stable.
MEDS: Vitamins, Procardia, and painkillers containing aspirin
VS: WT 250lbs, Height 5'8.
Gen: Patient appears moderately healthy. Random movements indicating anxiety; at some point patient gets emotional and tends to withhold some information. Patient seems troubled and in fear, maybe undergoing a trauma but no physical signs of recent accidents or bruises evident. Patient appears to have emotional trauma
Heart: S1>S2 at apex, RR R w/out murmurs, gallops, pulses 2+/equal bilaterally
Chest: A/P not inc; lungs: indistinct wheezing, trouble breathing as expected
Abdomen: Unremarkable to inspection w normal active bowel; sounds heard in the four quadrants. Liver span: 9.5 cm RM CL, 5 cm RMSL w no splenic dullness noted. Abdomen w/out any masses or organomegaly.
Pelvic Exam: Uterus retroflexed and regular sized w consistency.
Diagnostics: Urine dip negative; white count normal, possible uterus abnormalities evident
Probable polycystic ovarian syndrome (PCOS)
Probable poor egg quality
Admit to Dr. Whites service
VS: q 6h
MEDS: IVF, Surgery, Fertility drugs, clomiphene citrate, ovarian drilling
Pelvic u/s: STAT
GYN consult: STAT
Anticipate counseling from a professional on safe sex, contraceptives, and nutrition
The excessive bleeding during the menstrual cycle is an indicator of a problem in the reproductive system. Patients lifestyle is wanting and has contributed significantly to the difficulties evident as she tries to conceive (Cole, 2012). According to McNicholas et al. (2013), stress and weight issues can be leading factors to failure to get pregnant especially in women aged 35 and above. Patients daily routine encompasses excessive stress managing her Law firm, and her obesity is of class II. Patients symptoms suggest three probable conditions that may be hindering her from getting pregnant. The probable conditions are polycystic ovarian syndrome (PCOS), poor egg quality, or Endometriosis.
Polycystic ovarian syndrome is probable due to the patients menstrual cycle and her weight (Trikudanathan, 2015). Symptoms of PCOS include acne, irregular menstrual periods, obesity, and excessive hair growth. According to Franks (2013),PCOS is a condition whereby the small follicles fail to develop to mature and larger follicles that will release the eggs in the ovaries. The heavy and irregular periods may be an indicator of the condition despite having no history of the ailment (Futterweit, 2012). To manage the condition, the patient would require a change in lifestyle or medical attention, which may range from prescription drugs to surgery in extreme cases (Nandi, Chen, Patel & Poretsky, 2014). Under prescription drugs, the pregnancy rate per treatment cycle is higher than when one gets a surgery according to McCartney and Marshall (2016).
The other probable condition is poor egg quality. Due to the patients age, the quality of her eggs may be poor and may be the reason for the failed attempts to get pregnant (Mittal, Dandekar & Hessler, 2014). There are no symptoms associated with this condition except on speculation determined by ones age. However, there are possible methods the patient can use to get a child. One probable solution is the use of IVF (Cenksoy, Ficicioglu, Yildirim & Yesiladali, 2013). Women using donor eggs via IVF have a 55% chance to get a child per cycle (Chin et al., 2015).
Endometriosis is the third probable cause the patient fails to get pregnant. Endometriosis is a condition whereby tissues found in the endometrial tissue or uterus lining grow in the pelvis or abdomen outside the uterus (Iwabe & Harada, 2014). One symptom that indicated the probability of the condition was the excessive heavy menstrual periods of the patient. Moreover, the pain and bleeding during intimacy is an indicator of the condition. According to Koga et al. (2014), possible solutions would be surgery to unblock the fallopian tubes, IVF, or use of fertility drugs.
Cenksoy, P., Ficicioglu, C., Yildirim, G., & Yesiladali, M. (2013). Hysteroscopic findings in women with recurrent IVF failures and the effect of correction of hysteroscopic findings on subsequent pregnancy rates.Archives of gynecology and obstetrics, 287(2), 357-360.
Chin, H. B., Howards, P. P., Kramer, M. R., Mertens, A. C., & Spencer, J. B. (2015). Racial Disparities in Seeking Care for Help Getting Pregnant.Paediatric and perinatal epidemiology, 29(5), 416-425.
Cole, L. A. (2012). Hyperglycosylated hCG and pregnancy failures. Journal of reproductive immunology, 93(2), 119-122.
Franks, S. (2013). Polycystic ovary syndrome. Medicine, 41(10), 553-556.
Futterweit, W. (2012). Polycystic ovarian disease. Springer Science & Business Media.
Iwabe, T., & Harada, T. (2014). Inflammation and Cytokines in Endometriosis. In Endometriosis (pp. 87-106). Springer Japan.
Koga, K., Yoshino, O., Hirota, Y., Hirata, T., Harada, M., & Osuga, Y. (2014). Infertility Treatment of Endometriosis Patients. In Endometriosis (pp. 431-443). Springer Japan.
McCartney, C. R., & Marshall, J. C. (2016). Polycystic ovary syndrome. New England Journal of Medicine, 375(1), 54-64.
McNicholas, C., Zhao, Q., Secura, G., Allsworth, J. E., Madden, T., & Peipert, J. F. (2013). Contraceptive failures in overweight and obese combined hormonal contraceptive users. Obstetrics and gynecology, 121(3), 585.
Mittal, P., Dandekar, A., & Hessler, D. (2014). Use of a modified reproductive life plan to improve awareness of preconception health in women with chronic disease. Perm J, 18(2), 28.
Nandi, A., Chen, Z., Patel, R., & Poretsky, L. (2014). Polycystic ovary syndrome. Endocrinology and metabolism clinics of North America, 43(1), 123-147.
Trikudanathan, S. (2015). Polycystic ovarian syndrome. Medical Clinics of North America, 99(1), 221-235.
Ventura, S. J., Curtin, S. C., Abma, J. C., & Henshaw, S. K. (2012). Estimated pregnancy rates and rates of pregnancy outcomes for the United States, 1990-2008. National vital statistics reports: from the Centers for Disease Control and Prevention, National Center for Health Statistics, National Vital Statistics System, 60(7), 1-21.
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