1) R/O HIV infection

2) Amenorrhea 7 weeks- positive BHCG

3) Hx BA (childhood)
4) Past hx of cigarette and cannabis use
5) Allergic to PEN

SUBJECTIVE: 25 y/o G1P0 with LMP Jul/3/2015 who comes today with +BHCG test done 2 weeks ago. Denies bleeding
or pain. Complains of mild nausea w/o vomits. Prenatal care starting today. Not taking folic acid or prenatal vitamins.
This is an unplanned but desired pregnancy. Brings results of routine labs ordered by a friend who is a doctor. She was
called by lab due to abnormal result in HIV test. First time she does the HIV test. Denies any fever, chills, diarrhea, skin
lesions or other HIV-associated symptoms. Transmission route is most likely heterosexual contact. Has been with
current partner for 1 year. Partner was incarcerated several years ago due to aggression to another man. Denies any
incident of domestic violence, but recognizes he can turn hostile with others under the influence of alcohol. She feels
safe at home but is worried how he might react with her HIV diagnosis.
Medical history: bronchial asthma (last episode during childhood. Surgical history: no sx. Hospitalizations: in
childhood due to BA
Allergies: PEN. Toxic habits: past hx cigarette smoking (pack years: 3.5)-d/c 2 weeks ago, past hx cannabis use (d/c)
Blood transfusions: none
Gyn Hx: Menarche at 12, regular menses q28 days x 4-5 days, moderate flow, mild dysmenorrhea improved w/ NSAIDs.
Last pap: never
Sexual hx: Sexual debut at 18 y/o x 4 partners. Partners in last year: 1. STIs: chlamydia at 18 y/o (treated).
Contraception:
use of condoms.
OBJECTIVE: occasional
VS: BP: 110/60
HR: 80 No
RR:PCB
18 orT:pain.
36C No hx of abuse.
GEN: AAOx3
HEENT: no lesions in oral cavity
Nodes: generalized adenopathy
Lungs: CTAx2
Skin: no lesions
Breasts: no skin changes, masses or nipple discharge
Pelvic:
External: ASA
BUS: -MINT
Vag: w/e, w.s
Cervix: no lesions, no bleeding, os closed
Uterus: AV, 8-9cm
Adnexae: not tender, no masses

4th generation HIV test: reactive (date)

BHCG: +

ASSESSMENT: 25 y/o G1 w/ above hx, presenting amenorrhea of 7 weeks and +BHCG. Will confirm pregnancy w/ EV
US (IUP, missed abortion, ectopic pregnancy included in differential diagnoses). Most likely an IUP due to lack of pain or
bleeding. Not taking FA or prenatal vitamins; will prescribe. No pregnancy-related complications, except for mild
nausea. Counseled about ways to diminish them (frequent, dry meals) and monitor. Will order rest of 1st trimester labs.
Pap and cervical Gc/c were taken today. Patient brings results of 4th generation HIV test. Will order multispot (AB
differentiation) and CD4 and Viral load to confirm diagnosis (differential diagnoses include HIV infection or false reactive
test). Generalized adenopathy may reflect true infection. Based on history, possible infection secondary to
heterosexual contact. Oriented that, it is ideal that her partner gets tested. Provided support for this process, and was
also provided support in the case he turns violent and she feels unsafe at any moment. She was oriented about HIV
disease and was educated regarding risks of fetal transmission and measure to diminish this risk (use of HAART, IV AZT,
C/S if indicated, AZT for the baby, no breastfeeding). For health maintenance, will administer seasonal flu vaccine
when available.
PLAN:
1) RTC in 1 week
2) Labs ordered: Multispot for HIV 1 and 2, CD4, HIV RNA PCR, CBC, U/A, U/C, CMP, VDRL, Hepatitis profile, BTG, Indirect
coombs, Rubella titers
3) Tests ordered: EV US
4) Meds prescribed: Folic Acid 4mcg QD
5) F/U pap and Gc/c taken today
6) Education provided on: importance of FA supplementation, ways to diminish n/v in pregnancy, HIV disease, HIV and
pregnancy, domestic violence and resources for victims
7) Flu vaccine when available
Student
Name____________________________________________________________Date:_____