Posted: February 2nd, 2025

Teresa is a 34-year-old Hispanic G2P2002

Case #1: Teresa
History of Present Illness (HPI): Teresa is a 34-year-old Hispanic G2P2002. She presents to your office today at 10 weeks postpartum (PP) for her 6-week PP check. She underwent a C-section for failure to progress following a 20-hour labor with Pitocin augmentation. She was discharged from the hospital on day 2 postpartum without complications.

Teresa has had difficulty breastfeeding due to discomfort in her suture line and terrible pain in her right breast since discharge. She reports occasional chills but has not measured her temperature at home. She was seen by a lactation consultant in the hospital but says, “nothing is working,” and her son “cries all the time.” She is afraid to feed her son formula because her mother-in-law wants her to “keep trying to breastfeed.” She feels as if she has failed her son: “It was so easy with my first baby. I know my husband thinks I am a bad mother.”

Prior Medical History: None.
Prior Surgical History: Appendectomy (2000).
Current Medications: Prenatal vitamins, stool softener.
Allergies: None.
OB-GYN History: NSVD (2019) healthy female 7 lb 10 oz; C-section healthy male 8 lb 8 oz as per HPI. Menarche at age 12. Cycle length: 5 days. Frequency: every 28 days. Uses 4-5 tampons per day. No history of sexually transmitted infections (STIs). History of abnormal Pap smear in 2019, followed by a normal colposcopy. Last Pap (during recent prenatal care) was normal. HIV negative.
LMP: First PP menstrual cycle last week. Has not resumed sexual activity PP.
Contraception History: Oral contraceptives, condoms.

Social History: Lives with husband, mother-in-law, and children. Stay-at-home mom. Denies alcohol or recreational drug use. Never smoked. Her family speaks Spanish at home; she is fluent in English.
Family History: Unremarkable.
Review of Systems (ROS): Negative except as noted in HPI.

Physical Exam (PE):
VS: BP 110/70, P 90, RR 18, T 38.4°C, Weight 132 lbs.
Teresa’s C-section suture line is healing well without erythema or tenderness. No vaginal discharge or lesions. No cervical motion tenderness (CMT). Uterus is normal size, firm, and non-tender.

On breast exam, there is an erythematous, swollen, and painful area on the right breast. The rest of her physical exam is unremarkable.

Case Study #1: Teresa
Teresa, a 34-year-old Hispanic woman, presents at 10 weeks postpartum with significant challenges related to breastfeeding and emotional distress. Her history includes a cesarean section due to failure to progress during labor, and she reports persistent pain in her right breast and discomfort at the suture site. The physical examination reveals an erythematous, swollen, and tender area on the right breast, along with a fever of 38.4°C, suggesting mastitis. This condition, often caused by bacterial infection, is common in breastfeeding women and can lead to systemic symptoms such as chills and fever if untreated (Amir, 2019). Teresa’s emotional state is concerning, as she expresses feelings of inadequacy and guilt, exacerbated by pressure from her mother-in-law to continue breastfeeding despite her difficulties.

The management plan should address both her physical and emotional needs. Immediate treatment for mastitis includes antibiotics such as dicloxacillin or cephalexin, along with pain management using acetaminophen or ibuprofen (Spencer, 2021). Encouraging frequent breastfeeding or pumping from the affected breast is crucial to prevent milk stasis, which can worsen the condition. Teresa should also be reassured that her struggles do not reflect her capabilities as a mother. A referral to a lactation consultant for ongoing support and education on proper breastfeeding techniques may help alleviate her distress. Additionally, addressing her emotional well-being through counseling or support groups could provide her with coping strategies and reduce feelings of isolation (Dennis, 2020).
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Case #2: Joanna
History of Present Illness (HPI): Joanna is a 28-year-old Caucasian G4P1021. She is single, living with her father and 2-year-old daughter. She works part-time as a server at a local restaurant and does not have health insurance. She presents to your office at the community health center stating she is pregnant and wants OB care. She has not yet been evaluated for this pregnancy due to fear of taking time off work and financial concerns.

Prior Medical History: None.
Prior Surgical History: None.
Current Medications: None.
Allergies: Penicillin.
OB-GYN History: NSVD (2021) healthy female 6 lb 8 oz. Menarche at age 10. Cycle length: 3 days. Irregular cycles since menarche (every 20-30 days). Uses 2-3 tampons per day. No history of STIs. OB history includes two first-trimester elective terminations and one term vaginal delivery at 37 weeks. Denies complications during prior pregnancy, though her daughter experienced hypoglycemia and respiratory distress, requiring a 2-week NICU stay.
LMP: Approximately 5 months ago.
Contraception History: Condoms “sometimes.”

Social History: Lives with her retired father and daughter. Works as a restaurant server. Denies alcohol or recreational drug use. Currently smokes 1 pack/day (15 pack-year history). She and her mother are still paying for her daughter’s NICU stay. The child’s father is not involved.
Family History: Mother (deceased at age 55) had type 2 diabetes.
Review of Systems (ROS): Unremarkable except for dysuria (“it burns when I pee”) for the past week. Denies fever, chills, or flank pain. Reports thick white vaginal discharge and itching for the past month.

Physical Exam (PE):
VS: BP 108/68, P 72, RR 18, T 37.3°C, Weight 144 lbs.
Fundal height is approximately 20 cm with an audible fetal heart tone (FHT) of 160 bpm. On speculum exam, the cervix appears multiparous without lesions. Bluish discoloration of the cervix, vagina, and vulva is noted with thick, white discharge. No CMT on exam. Uterus is anteverted, non-tender, with fundus palpable at the umbilicus. The rest of her physical exam is unremarkable.

Wet mount reveals budding yeast. Urine dipstick shows 1+ leukocytes, trace blood, and 2+ glucose.
Case Study #2: Joanna
Joanna, a 28-year-old Caucasian woman, presents for prenatal care during her current pregnancy. Her history includes a term vaginal delivery and two first-trimester elective terminations. She reports dysuria, thick white vaginal discharge, and itching, which, along with the physical exam findings of bluish discoloration and yeast on wet mount, suggest a candidiasis infection. The presence of glucose in her urine raises concerns about gestational diabetes, particularly given her family history of type 2 diabetes in her mother (American Diabetes Association, 2022).

The initial management should focus on treating her candidiasis with antifungal medications such as fluconazole or topical clotrimazole. Given her symptoms and risk factors, screening for gestational diabetes using a glucose challenge test is essential. Joanna’s smoking habit, with a 15-pack-year history, poses significant risks to her pregnancy, including low birth weight and preterm delivery. Smoking cessation counseling and resources, such as nicotine replacement therapy or behavioral support, should be provided (Coleman et al., 2019).

Financial concerns and lack of health insurance are barriers to Joanna’s access to care. Connecting her with community resources, such as Medicaid or local prenatal care programs, can help ensure she receives consistent and affordable care throughout her pregnancy. Addressing her social determinants of health, including her financial strain and lack of support from the child’s father, is critical to improving her overall well-being and pregnancy outcomes (Lu et al., 2020).

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Case #3: Monica
History of Present Illness (HPI): Monica is a 43-year-old African-American G3P2102. She is separated from her husband of 20 years and works full-time as a legal secretary. About 8 months ago, she developed irregular periods with heavier flow until she stopped menstruating 3 months ago.

She is recovering from a “stomach flu” but reports daily nausea, vomiting, bloating, and decreased appetite for the past 3 weeks. She is concerned about a 12-lb weight gain over 3 months, attributing it to menopause. She presents today to discuss menopause symptoms and hormone replacement therapy.

Prior Medical History: Hypertension (2010), well-controlled.
Prior Surgical History: Cholecystectomy (2015).
Current Medications: Lisinopril 10 mg daily.
Allergies: None.
OB-GYN History: NSVD x2 (2015, 2019), healthy female infants (6 lb 8 oz, 7 lb 6 oz). First-trimester miscarriage (9 weeks) in 2014. Menarche at age 15. Cycle length: 7 days. Frequency: every 28 days. Uses 5-6 pads per day. No history of STIs. No history of abnormal Pap (last Pap 2 years ago).
LMP: Approximately 3 months ago.
Contraception History: Condoms; past use of oral contraceptives.

Social History: Lives with elderly father and two daughters. Separated from her husband for 6 months.
Family History: Mother deceased at age 60 (breast cancer). Father alive at age 70 (hypertension).
Review of Systems (ROS): Unremarkable except as noted in HPI.

Physical Exam (PE):
VS: BP 130/78, P 78, RR 18, T 36.1°C, Weight 152 lbs.
Physical exam is unremarkable except for a palpable 12-14 week-sized uterus on bimanual exam.

A fetal heart tone of 145 bpm is detected via Doppler. The intake nurse reports a positive urine pregnancy test.

Monica is in disbelief.

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