NUR MISC-OB Cases 39-51

NUR MISC-OB Cases 39-51 ase# 39: Zelda ID: 37 y/o African American female with 37 y/o African American husband CC: Fertility issues HPI: Patient is a G1P1 present with her husband to discuss stress over lack of success in conceiving. Patient has a 4 y/o daughter from a previous relationship w/o complications and delivered vaginally. She was on OCP from one and a half years ago and stopped having regular menstrual cycles once she discontinued them. She reports having a period every 5 to 7 weeks. Her past medical history is mild depression and on Imipramine 150 mg qhs for the last 8 months. She denies the history of STDs, abnormal PAPs, smoking, alcohol, or drugs. Her partner reports good health, no sexual history problems, no previous STD hx, and no previous medical history. He has a history of smoking, drinking alcohol, and amphetamines to stay awake as a truck driver. A: (1) Encounter for Procreative Counseling (2) Infertility (3) Mild Depression P: (1-2) Educate on risk factors for infertility: high stress levels, high caffeine intake, heavy alcohol use, increased maternal and parental age, use of lubricants such as KY Jelly, obesity, vigorous exercise, Tobacco use by female and male partner can cause subfertility and can be improved by at least a year of cessation. Heavy alcohol use in a male partner can cause abnormalities in gonadal function, impotence, and reduce testosterone production. Diets low in fats, enriched antioxidant food, and rich with vegetables. Avoid environmental pollutants and toxins; Avoid sexually transmitted infections by preventing safe sex practices. Advised husband to avoid amphetamine use as recreational drugs can reduce fertility in both men and women. Advised husband on smoking cessation, stop amphetamine use, and reduce alcohol intake to improve overall quality of health and improve fertility. Advised patient to reduce her intense and vigorous workouts to help reduce stress on her body that could be impeding her fertility. Suggest sexual intercourse 2-3 times a week from soon after menstrual cycle ends to make sure intercourse falls within the most fertile period which is 2 days before ovulation. Advise patients to limit caffeine intake to 1-2 cups a day. Advised couple to determine fertility window which falls within 5 days prior to ovulation. The most fertile days are the three days leading up to ovulation. The best way to determine this window is to keep track of your menstrual cycle on a chart, diary, or free period-tracker app on your phone. She can record the first day her menstrual cycle as day 1 and the last day before the next menstrual cycle starts. Diagnostics for the patient can be FSH, estradiol, and AMH level. Order a semen analysis of husband to be collected 2-7 days of ejaculatory abstinence. Recommend he schedule a physical exam to rule out any other issues of infertility with examination and blood tests. Advised the couple to work on ways to reduce stress at home and encourage them that it improves chances of fertility. RTC in 2 months to f/u on results and any need for further assessment. (3) Patient informed her that she may continue her Imipramine 150 mg qhs as it has a low teratogenic effect on pregnancy. She can continue treatment to prevent worsening of depression symptoms or postpartum depression after pregnancy. Case# 40: Zelda ID: 37 y/o African American female accompanied by 37 y/o African American male husband CC: f/u on Fertility issues HPI: Patient is G1P1 who is here for her fall complaining of continued fertility issues after 20 months of trying. Patient has reduced her exercise routine to 10-12 miles a day. The patient's blood results were normal. Her husband said his physical exam was normal, but the sperm test showed slow sperm motility. He has stopped his amphetamine use, alcohol use to only 0-2 drinks a week, and quit smoking. Patient and husband have no other complaints or medical concerns and want to know what their next steps can be to conceive a child. A: (1) Infertility Encounter P: (1) Patient advised to continue trying through natural conception methods and to see a specialist for further evaluation about infertility options. Husband may be a candidate for ART options. IVF is an option further down the road if the couple cannot conceive. Congratulate the couple on making lifestyle changes to improve their health and fertility. #41 & #42) Elisa 32 year nulliparous female well known to the clinic presents today at 36 2/7 weeks gestational age for a scheduled prenatal visit. Long time history migraine headaches. In this pregnancy her BPs are ranging from 125/85 to 135/90 at previous prenatal visits. Over the past 2 days she has not been able to perform usual activities due to her symptoms. Reports continued fetal movement, no contraction