Jackie is a 31-year-old pregnant patient (2nd child, two different fathers) single mother of a 6-year-old who is coming for prenatal care since she suspects she is pregnant. She is no longer with the father of Robby, her firstborn. She indicates "pretty serious partying" with the likely father of the baby. By pretty serious partying she means 10-12 drinks per occasion, one to two times per week, plus intermittent methamphetamine use.
• Which clinical information would be most critical for you to collect in the first visit?
• What are the greatest risk factors for substance use disorder for this patient?
• Which harm reduction strategies would you recommend?
• Identify your city. Then refer this patient to three agencies near you that would support positive health outcomes for this patient. (These agencies must not have been used in past discussion posts). What was your rationale for choosing these three agencies?
o Willow Women’s Center
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Pretty Serious Partying
Full Answer Section
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- Specificity of Methamphetamine Use: Clarify frequency, route of administration (snorting, smoking, injecting), last use, and any associated behaviors (e.g., sharing needles).
- Other Substances: Inquire about tobacco, cannabis, opioids, benzodiazepines, or other illicit drug use.
- Polysubstance Use: Understand the combination and patterns of all substances used.
- Prior Attempts to Quit/Reduce: Assess her readiness to change and any previous experiences with substance cessation.
- Comprehensive Medical History, Focusing on High-Risk Conditions:
- Previous Pregnancy History: Details of Robby's birth (gestational age, birth weight, complications, any developmental concerns related to prenatal exposures).
Sample Answer
This is a complex and high-risk case requiring immediate, sensitive, and comprehensive care. Jackie's situation highlights the profound intersection of social determinants of health and maternal-child well-being.Clinical Information Most Critical to Collect in the First Visit:
Given Jackie's history, the most critical clinical information to collect during this first visit centers on immediate risk assessment for both her and the potential fetus, and establishing a baseline for ongoing care.- Confirmation of Pregnancy and Gestational Age:
- Urine/Blood Pregnancy Test: To confirm pregnancy definitively.
- Last Menstrual Period (LMP) and Estimated Due Date (EDD): Crucial for dating the pregnancy.
- Early Ultrasound Scan: This is paramount to confirm viability, rule out ectopic pregnancy, accurately date the pregnancy (especially given irregular periods or uncertain LMP due to substance use), and identify any immediate structural abnormalities that might be linked to early exposure.
- Detailed Substance Use History:
- Specificity of Alcohol Use: While she stated "10-12 drinks per occasion, one to two times per week," clarify types of alcohol, actual quantities (e.g., standard drink sizes), and the exact period of consumption relative to conception. When did "serious partying" start and, more importantly, when did it stop or reduce?
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