OBGYN Tina Sandler - Part3 (GRADED A)

Document Content and Description Below

Tina Sandler – PART 3 – OBGYN CC – high blood pressure Diagnosis –preeclampsia 4asc/1hpi HTN, heartburn, headaches(stress?), hand/feet swelling, fetus alive Tests- UA, CBC, CMP, Creatinine ... 24hr Problem Statement: ( Demographic description – chief complaint – Hx and PE key findings – risk factors ) Tina Sandler is a 29-year-old female G5P2111 here at 33 weeks (third trimester) for evaluation of High blood pressure (146/90), having missed visits after being seen at 24 weeks gestation. Increased frequency of headaches, as well as heartburn. BP is 146/90 increased from last visit, fundal height appropriate for gestation, FHT=not detected, however fetal movements detected on PE, No bruising noted. Edema is present: +1 pedal edema and +1 ankle edema with edema in hands as well. CC: Tina Sandler is a 29-year-old female G5P2111 here at 33 weeks (third trimester) for evaluation of High blood pressure (146/90) HPI: Patient reports she checked her BP at a pharmacy and it came out high. She has missed her f/u visits and now reports continued headaches triggered by relationship stress, as well as heartburn and edema of her extremities Meds: Prenatal vitamins PMH: Patient has a history of ectopic pregnancy and preeclampsia and 3rd trimester loss of pregnancy. SH: Patient reports that she is not currently smoking cigarettes, drinking alcohol, or using recreational drugs while pregnant ROS: Only positive findings are seen in HPI Physical Exam: VS: Pulse – 82; BP – 146/90 (138/82 standing) RR – 18; T – 97.4F (36 C); SpO2 – 94% Extremities: +1 pedal edema, +1 pretibial edema to knees, also finger edema. ASSESSMENT/PLAN Test Results: • Urinalysis: Proteinuria +1 • CBC: Slight elevation in WBC • CMP: Normal • Creatinine, urine 24hour: Normal • Obstetric ultrasound: Single live intrauterine gestation in cephalic position, FTH=147bpm. Placenta posterior, grade 0 without previa. Cervical length 3.2cm, Normal amniotic fluid index. Spontaneous body/limb motion. • Drug toxicology screen: Normal – no drugs detected • Uric acid - serum: Normal Management Plan • Continue outpatient monitoring – increased to 1x/2x week – check BP, urine dipsticks, blood analysis (platelet counts, liver enzymes, renal function) • Fetal monitoring: US and NST • Patient education on signs of sever preeclampsia or fetal distress, avoid physical exertion • Antihypertensive drug therapy – Labetalol / Hyralazine / Nifedipine / Methyldopa [Show More]

Last updated: 1 year ago

Preview 1 out of 6 pages