To review an approach to history and physical exam for the first prenatal clinic visit; and to practice prescribing exercise and SMART Goal setting in context of pregnancy. 22yo F presenting for first prenatal visit to family medicine clinic

Claire is a 35-year-old G1 with Type 1 DM. She had an episode of pyelonephritis at 26 weeks gestation and did well following this, and was last seen at 30 weeks. At 32 weeks Claire presents in St. Catharines with a headache and RUQ pain. Her husband says that Claire’s swelling, especially in her face, has worsened over the past 2 days. BP is 160/105. FH is normal. She has 4+ urine protein. Hb 142 g/L, platelets 152, AST 67, ALT 75, INR/PTT normal, fibrinogen 5.8 g/L, glucose 6.5 mM/L, creatinine 100 uM, urea 4.2 mM. Urinary ketones are negative. She is given morphine and oral labetalol. Her symptoms settle and BP is 145/95. Ultrasound shows a cephalic fetus with normal head and femur measurements but the abdominal measurement lags by 3 weeks. There is marked oligohydramnios. Doppler studies are abnormal. MUMC is called and a decision is made to transfer Claire. On arrival, she complains of severe RUQ pain. BP is 170/110. She has made very little urine and it is dark tea coloured. Hb 137 g/L, platelets 100, AST 265, ALT 310. Her urinary protein to creatinine ratio is 500 mg/mmol. She is given a dose of nifedipine and MgSO4 is started. A decision is made to do an immediate C/S with spinal.

To review an approach to history and physical exam for the first prenatal clinic visit; and to practice prescribing exercise and SMART Goal setting in context of pregnancy. 22yo F presenting for first prenatal visit to family medicine clinic

Claire McFadden is a 16- year-old high school student, living with T1D since age 10, who is currently pregnant (G1). Claire has struggled with her diabetes management in the past but is trying to keep her sugars at target now that she knows she is pregnant. Her most recent HbA1C was 7.8%, and she is using an insulin pump. Claire is being followed concurrently by her endocrinologist and has had microalbuminuria and mild non-proliferative retinopathy but no other diabetic complications. She has been normotensive with a usual BP of 110/70. She was told to start prenatal vitamins with extra folate as well as to discontinue her ACE inhibitor when her pregnancy test was found to be positive. Claire was also started on low-dose ASA (LDASA) at 12 weeks. Her partner, Dave, is 18 years old and is unemployed, having graduated high school in the summer. Claire is living with Dave in her aunt’s apartment. Her pregnancy was unplanned, but she is now excited to become a mother. She is planning to take a year off from high school and then return to complete her high school diploma. Dave is unhappy about this and feels she should stay at home to take care of the baby. They have argued about this, and Dave feels it is Claire’s own fault if she does not like making sacrifices as she could have gotten an abortion like he wanted. Claire worries about Dave’s temper, explaining that when he found out she was pregnant, he yelled at her and then disappeared for a week. She thinks he will come around once the baby is born.

To review an approach to history and physical exam for the first prenatal clinic visit; and to practice prescribing exercise and SMART Goal setting in context of pregnancy. 22yo F presenting for first prenatal visit to family medicine clinic

Claire McFadden is a 16- year-old high school student, living with T1D since age 10, who is currently pregnant (G1). Claire has struggled with her diabetes management in the past but is trying to keep her sugars at target now that she knows she is pregnant. Her most recent HbA1C was 7.8%, and she is using an insulin pump. Claire is being followed concurrently by her endocrinologist and has had microalbuminuria and mild non-proliferative retinopathy but no other diabetic complications. She has been normotensive with a usual BP of 110/70. She was told to start prenatal vitamins with extra folate as well as to discontinue her ACE inhibitor when her pregnancy test was found to be positive. Claire was also started on low-dose ASA (LDASA) at 12 weeks. Her partner, Dave, is 18 years old and is unemployed, having graduated high school in the summer. Claire is living with Dave in her aunt’s apartment. Her pregnancy was unplanned, but she is now excited to become a mother. She is planning to take a year off from high school and then return to complete her high school diploma. Dave is unhappy about this and feels she should stay at home to take care of the baby. They have argued about this, and Dave feels it is Claire’s own fault if she does not like making sacrifices as she could have gotten an abortion like he wanted. Claire worries about Dave’s temper, explaining that when he found out she was pregnant, he yelled at her and then disappeared for a week. She thinks he will come around once the baby is born.

Claire McFadden is a 16- year-old high school student, living with T1D since age 10, who is currently pregnant (G1). Claire has struggled with her diabetes management in the past but is trying to keep her sugars at target now that she knows she is pregnant. Her most recent HbA1C was 7.8%, and she is using an insulin pump. Claire is being followed concurrently by her endocrinologist and has had microalbuminuria and mild non-proliferative retinopathy but no other diabetic complications. She has been normotensive with a usual BP of 110/70. She was told to start prenatal vitamins with extra folate as well as to discontinue her ACE inhibitor when her pregnancy test was found to be positive. Claire was also started on low-dose ASA (LDASA) at 12 weeks. Her partner, Dave, is 18 years old and is unemployed, having graduated high school in the summer. Claire is living with Dave in her aunt’s apartment. Her pregnancy was unplanned, but she is now excited to become a mother. She is planning to take a year off from high school and then return to complete her high school diploma. Dave is unhappy about this and feels she should stay at home to take care of the baby. They have argued about this, and Dave feels it is Claire’s own fault if she does not like making sacrifices as she could have gotten an abortion like he wanted. Claire worries about Dave’s temper, explaining that when he found out she was pregnant, he yelled at her and then disappeared for a week. She thinks he will come around once the baby is born.

This session provides you with an overview of how to recognize and respond to IPV, including epidemiology, signs and symptoms of exposure, approaches to assessment (including safety) and response (including referrals).

Claire brings infant Marie to her family physician for the 2-month well baby visit, alone. When asked how she and Dave are adjusting, she mumbles “fine.” Marie has been “fussy” during the night, and Claire is finding breast-feeding to be a challenge. Newborn examination is performed, the Rourke baby record is completed and no concerns noted. Claire is motivated to breastfeed but she says Dave thinks formula is better and is worried the baby is not getting enough milk and that is why she is crying. “He says it is my fault.” The benefits of nursing to mom and baby are reviewed, along with formula options, and a referral to a lactation consultant is made. Two weeks later, the office receives an “urgent” call from Claire’s aunt asking that she be seen. Notably, Claire did not bring in baby Marie for a follow-up, in spite of a reminder call from the office. Claire is booked as the last appointment of the afternoon, and reception staff comment they heard screaming in the background while Claire’s aunt made the call. One receptionist says “things are not right” in the McFadden family.

Marie is brought in periodically to the office by Claire and is 2 months behind on routine 1-year vaccinations at 14 months of age. At today’s visit she is brought in by Claire’s aunt. Her aunt asks you if you have heard the latest? Child Protection Services (CPS) is now involved as Dave “hit the baby” and caused a nosebleed and a small bruise to her forehead. Marie was seen at the Urgent Care as it was a Sunday, and the physician there notified CPS. Dave has now moved out of the home and will only be allowed supervised visitation if he completes anger management counselling and parenting classes. “Finally, he will get the help he needs!” the aunt exclaims. You ask about Claire and her aunt says she is exhausted and asked her aunt to bring Marie to this appointment. Claire’s aunt wonders if Claire is also embarrassed by the breakdown of her relationship with Dave, and feels guilty that she could have done more to protect Marie.

This session provides you with an overview of how to recognize and respond to IPV, including epidemiology, signs and symptoms of exposure, approaches to assessment (including safety) and response (including referrals).

Claire brings infant Marie to her family physician for the 2-month well baby visit, alone. When asked how she and Dave are adjusting, she mumbles “fine.” Marie has been “fussy” during the night, and Claire is finding breast-feeding to be a challenge. Newborn examination is performed, the Rourke baby record is completed and no concerns noted. Claire is motivated to breastfeed but she says Dave thinks formula is better and is worried the baby is not getting enough milk and that is why she is crying. “He says it is my fault.” The benefits of nursing to mom and baby are reviewed, along with formula options, and a referral to a lactation consultant is made. Two weeks later, the office receives an “urgent” call from Claire’s aunt asking that she be seen. Notably, Claire did not bring in baby Marie for a follow-up, in spite of a reminder call from the office. Claire is booked as the last appointment of the afternoon, and reception staff comment they heard screaming in the background while Claire’s aunt made the call. One receptionist says “things are not right” in the McFadden family.

Marie is brought in periodically to the office by Claire and is 2 months behind on routine 1-year vaccinations at 14 months of age. At today’s visit she is brought in by Claire’s aunt. Her aunt asks you if you have heard the latest? Child Protection Services (CPS) is now involved as Dave “hit the baby” and caused a nosebleed and a small bruise to her forehead. Marie was seen at the Urgent Care as it was a Sunday, and the physician there notified CPS. Dave has now moved out of the home and will only be allowed supervised visitation if he completes anger management counselling and parenting classes. “Finally, he will get the help he needs!” the aunt exclaims. You ask about Claire and her aunt says she is exhausted and asked her aunt to bring Marie to this appointment. Claire’s aunt wonders if Claire is also embarrassed by the breakdown of her relationship with Dave, and feels guilty that she could have done more to protect Marie.

Claire brings infant Marie to her family physician for the 2-month well baby visit, alone. When asked how she and Dave are adjusting, she mumbles “fine.” Marie has been “fussy” during the night, and Claire is finding breast-feeding to be a challenge. Newborn examination is performed, the Rourke baby record is completed and no concerns noted. Claire is motivated to breastfeed but she says Dave thinks formula is better and is worried the baby is not getting enough milk and that is why she is crying. “He says it is my fault.” The benefits of nursing to mom and baby are reviewed, along with formula options, and a referral to a lactation consultant is made. Two weeks later, the office receives an “urgent” call from Claire’s aunt asking that she be seen. Notably, Claire did not bring in baby Marie for a follow-up, in spite of a reminder call from the office. Claire is booked as the last appointment of the afternoon, and reception staff comment they heard screaming in the background while Claire’s aunt made the call. One receptionist says “things are not right” in the McFadden family.

Marie is brought in periodically to the office by Claire and is 2 months behind on routine 1-year vaccinations at 14 months of age. At today’s visit she is brought in by Claire’s aunt. Her aunt asks you if you have heard the latest? Child Protection Services (CPS) is now involved as Dave “hit the baby” and caused a nosebleed and a small bruise to her forehead. Marie was seen at the Urgent Care as it was a Sunday, and the physician there notified CPS. Dave has now moved out of the home and will only be allowed supervised visitation if he completes anger management counselling and parenting classes. “Finally, he will get the help he needs!” the aunt exclaims. You ask about Claire and her aunt says she is exhausted and asked her aunt to bring Marie to this appointment. Claire’s aunt wonders if Claire is also embarrassed by the breakdown of her relationship with Dave, and feels guilty that she could have done more to protect Marie.