differential diagnosis
List (no explanation/discussion) the most likely differential diagnosis for the 2 pregnancy symptoms as noted in the OV. Consider her N&V of pregnancy as 1 symptom.
Write your differential correctly. Include the normal in your differential diagnosis.
Office Visit Guidelines
The midwifery management process is a way of thinking critically and systematically. It will help you in developing your clinical judgment skills. We all use this
process daily in midwifery practice with every patient contact. Please be sure to KNOW the 7 steps of the management process in Varney for clinical practice and for
the exam in this course. This course is specifically designed to develop critical thinking skills. We expect you to follow these guidelines when dealing with issues
presented by a patient. Other terms that will be useful are defined in the glossary below.
The office visit is a clinical simulation. It is the closest thing that we as faculty have to evaluate your visit with a client, the application of the midwifery
management process, and content learned without being in the clinical setting with you. NM617 is often the first exposure to antepartum care for many of you. The
content is broad and deep. (Probably better stated as, there’s a lot to know!) This course help’s you think like a midwife’. We are guiding you in the first steps
in role transition from nurse to midwife. We don’t expect you to come into this course with this knowledge! In aIDition to antepartum care content, we are teaching and
refining critical thinking skills that are essential to midwifery practice. Feedback on office visit assignments is essential in assisting you in your development of
these critical thinking skills. To get this feedback in a timely manner and continue on in the course, please plan ahead when submitting assignments, and allow for
faculty grading time when you project your date of completion for the course.
Here are a few helpful hints to get you started in the right direction.
1. Assume pregnancy. No need to R/O gyn problems such as amenorrhea. Assume all women have had a positive pregnancy test prior to your encounter. If they weren’t
pregnant, they would be in the Women’s Health course!
2. Assume wanted pregnancy. She has already made some initial decisions if she made an appointment for prenatal care with you. No need to write up, if she wants to
terminate, then I would do this¦. This will help you to stay focused on the intent of the office visit.
3. Don’t look for zebra’s, deal with only the most likely. Here is an example: A woman comes to see you for a routine visit at 10 weeks gestation and reports LLQ
pain. You would think in your mind, It’s most likely round ligament pain as this is her regular visit, she didn’t call prior about this, it is very common; but she is
10 weeks, and it could be an ectopic. If the assignment asks you for a differential diagnosis, you would write in your differential diagnosis list, round ligament
pain, R/O ectopic. You would NOT need to include, R/O torsion of the fallopian tube, R/O bowel obstruction, R/O ovarian cancer. (If she had either of the first two,
she would most likely be writhing in pain in the ER, not talking with you in your office, and the 3rd is highly unlikely in reproductive aged women.) Remember this is
care of women who are pregnant, not sick. This is a wellness based course not illness based content. There is a difference in approach between dealing with illness
and wellness. Normal is the most likely diagnosis in pregnancy. Following this guidance if asked to write a differential diagnosis will prevent losing points.
4. Be detailed in your teaching if it’s pertinent to the office visit in your plan. Remember that a midwifery plan for pregnancy care has lots of specific teaching and
reassurance of normalcy when appropriate. Pregnancy is a normal process and it is essential that this is reflected in your counseling and teaching during prenatal
care. If an Office Visit question asks you to write verbatim, then please write verbatim. (If you do not know what this means, an on-line dictionary is helpful! Here’s
one you can bookmark, it’s excellent~
5. Know the difference between risk factor and potential problem. A risk factor is something that the client comes to you with; a potential problem is something she
may develop due to her risk factor(s). See the glossary below for definitions.
6. Watch the use of expensive tests and technology that do not have an indication based in the evidence. Use only when there’s an indication and evidence based
rationale. Although this may contradict common medical practice, it reflects ideal practice based in midwifery philosophy (and we are teaching you the ideal!)
7. Appropriate and respectful language use is an expectation in all AP graded assignments. Demonstrate a sensitivity of the use of language as it relates to women-
centered care. For example, rather than use the term, chief complaint, use the term, report of symptoms. It more accurately reflects the actual situation and is
more respectful. Often, women are reporting their pregnancy discomforts such as heartburn, itching, and nasal congestion; this is different than complaining’ about
them. Talking to women using during the visit childish terms such as tummy’ , or pee’, or calling her mommy’ is often perceived as offensive and demeaning. You will
learn more about this in Module 2! Following this advice in your forum posts and your OV assignments will prevent you from losing points.
8. Please use only your course texts/references for the Office Visits. The Office Visits do not require APA formatting or a reference list. Answer the question that is
asked.
Glossary
Please use the following definitions as appropriate when writing your office visit assignments. I encourage you to have this handy to review especially when you 1st
start with the assignments. This glossary does not review all of the 7 steps of the midwifery management process, but does give you definitions and guidance on the
components that may need some explanation.
Data Gathering
Subjective
This is what the patient tells you, and the information you elicit through questioning. This is why she came her main concern’. This is where you ask about her
personal history medical, surgical, menstrual, etc., and asks questions about any issues that you need more data on that may be pertinent to her specific case. Be
complete, and always ask the next question until all pertinent questions are asked. When writing this out, avoid the use of terms such as chief complaint’, as this is
not an accurate way of describing most client encounters. Most women are not complaining: they are reporting symptoms or concerns to you, and looking for guidance or
assistance.
Objective
This is your physical exam, lab or test results that you can have the results of for this visit (an example would be a urine dipstick, or a wet prep.) Include any
concrete observations that you can make at this visit. Describe what you see, hear, feel, and/or smell. Do not give an opinion. Do not include labs that you plan to
get at a later time, or won’t have the results of for this encounter. If you plan to get the particular lab at a later date (for example: 1 hour GTT), then this goes
in plan. Data that you can gather at this encounter to use in today’s assessment goes here (for example: urine dipstick). Other data you would like to obtain (USN for
example) goes in plan, as you plan to get it later.
Assessment
This is what you think is going on, your opinion based on the data gathered above. Other terms for this are problem list, diagnosis list, issues to be aIDressed. Your
assessments are listed as a diagnosis (example: IUP at 8 weeks), as a rule out, (example: R/O ectopic), or as a differential diagnosis (example: R/O ectopic vs. round
ligament pain), or as a specific issue to be aIDressed (concern about her activity level in pregnancy). When all findings from the known data are normal, WNL is listed
in your assessment as well (example, uterine growth WNL, or size = dates) Go a step further to your opinion what do you think is going on. You can only use data you
know in an assessment list.
Risk Factor
This is something the client comes to you with she has it now, and it has potential problems attached. Examples of risk factors that clients may have are: obesity,
poor diet, smoking, and hazardous substance exposure at work. Each risk factor has potential problems.
Potential Problems
These are things that could happen, but have not yet happened due to her problems that you have noted in your assessment. For example, if a woman has inadequate
weight gain’ as a problem, her potential problems will include IUGR, and preterm labor.
Plan
What you plan to do, to advise, to say, to discuss, and to teach based on the data gathered and your assessment of that data. Included in plan should be tests or lab
work, medications, treatments, consultation or referral, and patient teaching and reassurance. (Patient teaching and reassurance of normalcy are a major part of our
work as midwives! It is essential that you include this when appropriate.) The plan for a next visit is listed here (example: revisit in 2 weeks). In this course, when
writing out your plan, please do not break down your plan into components (educative, therapeutic, etc) but you should consider them in your thinking as you formulate
your plan.
Evaluation of Plan
This is what you would do to determine the effectiveness of your plan. So look back to your plan. For example: if your plan included specific dietary counseling,
evaluation of your plan would be to review diet diary to assess dietary changes. Do not use the nursing outcome based objectives based on what you would see, state
what you would do. For example if a client had anemia as a problem, and your plan included iron supplementation and diet changes, then your evaluation of plan would
be to recheck her H&H in 2-4 weeks, rather than her H&H will rise¦¦ The evaluation section is often very brief, assess this or re-check that, not wordy and
explanatory. (we do ask for this in any of the OV’s)
Jermaine Byrant
Nicole Johnson
OVER
RATING
YEARS
