Focused SOAP-Hypertension in Pregnancy Paper

Focused SOAP-Hypertension in Pregnancy Paper

Patient’s Particulars

Initials: J.R

Age: 42years

Gender: female

Race: African-American

Chief Complaint: headache and abdominal pain for 3days

History of T Presenting Illness:

J.R a 42years old African American female comes to the emergency department complaining of a headache, abdominal pain, and general body malaise for three days. The headache was of gradual onset at the temporal region radiating towards the occipital region. The pain was throbbing in nature, aggravated by bending and mild exertion and relieved by taking analgesics. The headache was associated with generalized body malaise, progressive blurring of vision, and confusion. The patient also complains of abdominal pain at the epigastric region and radiates to the left and right upper quadrant. Epigastric pain is aggravated by meals and relieved by drinking cold water or milk. The pain is associated with reduced appetite, heartburn, reflux, and nausea. However, the patient denies a history of abdominal bloating, vomiting, constipation, and diarrhea. Focused SOAP-Hypertension in Pregnancy Paper

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Current Medication: J.R is currently on methyldopa 250mg twice a day and metformin 500mg twice a day.

Gynecology History: The patient is married and lives with the husband and two children: 15 years and 12 years. Her menarche was at the age of 15years, regular 28 days cycle for 3days with a normal flow. She denies a history of dysmenorrhea. Implanon has been her family planning method of choice since she got married. She denies having multiple sexual partners and contracting sexually transmitted diseases.

Obstetrics History: the patient is para2+1gravida 4. Her first delivery was 15 years ago, spontaneous vertex delivery at term with no reported post-partum complications. The child is alive and healthy. Her second delivery was 12 years ago vertex spontaneous delivery at term with no complications. Her 3 pregnancy was 2 years ago which she had a spontaneous miscarriage at 13weeks gestation. She is currently pregnant at 6 months.

Past Medical History

The patient is a known hypertensive and diabetic (type 2DM) diagnosed one year ago. Focused SOAP-Hypertension in Pregnancy Paper

Past Surgical History

No major or minor surgical history

Social History

J.R is a 42-year-old African American female who has been a cashier in a bookstore for 3 years. She has been married for 10 years in a monogamous marriage, with two children, a girl aged 15 years and a boy aged 12 years. She regularly attends church and is an active member of the church choir and ushering team. She denied illicit drug use and tobacco smoking. She is a social drinker, 4-5 bottles of beer every month during social gatherings.

Family History

The patient has one sibling aged 40 years old (no PSH or PM). Her mother is 60 years old, alive, with a history of hypertension and type 2 DM, her father is 70 years old, alive, with a history of hypertension. Parents have been married for 45 years. The maternal grandmother is deceased (2006) and the maternal grandfather is 90 years old living with hypertension and type 2 DM. Both the paternal grandmother and (2008) and grandfather (2013) are deceased. Children are 15y/o and 12y/o alive and well.  Focused SOAP-Hypertension in Pregnancy Paper

REVIEW OF SYSTEMS:

General: the patient presented to the office accompanied by her spouse. She complains of having a headache, dizziness, headaches, memory loss, confusion, loss of appetite, nausea, abdominal pain, heartburn, and reflux

Cardiovascular: patient denies chest pain, palpitations, dyspnea, and paroxysmal nocturnal dyspnea

CNS: the patient denies lightheadedness, syncope, tingling in the lower and upper extremities

Respiratory: The patient denies substernal chest pain, difficulty in breathing, cough, wheezing shortness of breath, exposure to TB, or second-hand smoke. Up to date with flu immunization.

HEENT: The patient denies head trauma, epistaxis, hearing loss, ringing in the ears, eye, and ear discharge. She denies difficulty in swallowing food, pain in swallowing food. The last dental exam was three months ago.

Musculoskeletal: the patient has bilateral +1 pedal edema, up to the ankle joint, pitting, and non-tender. She denies joint pains, stiffness, back pains, and muscle pain.

Emotional: The patient denies low mood, sadness, anxiety, or depression.

Neurological Maintains a normal gait, no tremors or seizures, has tingling and numbness of the palmar side of the first three digits of the right hand.

Skin: No bleeding, rashes, or other lesions, slightly warm to touch.

Endocrine: no bruising, no night sweats, health/cold intolerance, no swollen lymph nodes or blood disorders.

OBJECTIVE DATA

Physical Exam:

Vital signs: Taken with the patient at rest, seated in a chair. BP – 176/92mmHg; PP – 110beats/min; RR – 24cycles/min; T – 91.6; Ht 5’3” Wt 110lb; BMI 21.50

General: Well-groomed 42-year-old female in moderate pain over the right wrist joint, Alert and Oriented in time, place, and person, afebrile and with an affluent effect.

Neck: The neck’s range of motion was full with no swelling of the cervical or occipital lymph nodes. Focused SOAP-Hypertension in Pregnancy Paper

Chest: No scars, moved symmetrically with respiration, no nipple discharge, no palpable masses, tenderness, or axilla lymphadenopathy.

Lungs: Non-labored breathing, chest moved symmetrically with exhalation and inhalation, and lung fields were bilaterally clear with auscultation.

Heart: S1 and S2 heard, strong pulses and a prompt capillary refill of fewer than 2 seconds, no edema.

Gastrointestinal: Abdomen has a normal contour with no scars.  it is distended with a palpable fundal height at 26weeks. The fundal lie is longitudinal with transverse presentation. There is a regular fetal heart rate on auscultation.

Genital/Rectal: V-shaped hair distribution, no swellings or discharge. Visual inspection of the rectum reveals no fissures, masses, or bleeding. Has soft and brown stool.

Psychiatric: The patient is alert to verbal stimulation with prompt responses, in moderate pain, and good eye contact.

Skin: the skin is slightly warm to the touch, with no signs of bruising or lesions.

Assessment

Differential Diagnosis

Preeclampsia is the presence of systolic blood pressure greater than 140mmhg or diastolic pressure greater than 90 at least on two separate occasions four hours apart. Signs and symptoms of preeclampsia are headaches, visual disturbance, dyspnea, edema, epigastric pain, and malaise (Rana, et al, 2019). Risk factors for preeclampsia are older than 40years, black race, chronic hypertension, diabetes mellitus, and high body mass index. The patient presents with symptoms similar to those of preeclampsia and has the risk factors; headache, epigastric pain, blurring of vision, confusion, lower limb swelling, and dizziness.

Chronic hypertension is elevated blood pressure above 140/90mmhg, diagnosed before pregnancy or before 20weeks gestation (Battarbee, et al, 2020). The patient was diagnosed to have hypertension one year ago.

Superimposed preeclampsia on chronic hypertension is characterized by new onset of proteinuria in a woman with hypertension but no proteinuria before 20weeks gestation. The patient is known to have hypertension but did not present with proteinuria before 20 weeks gestation. Focused SOAP-Hypertension in Pregnancy Paper

Plan

Laboratory and Radiological Tests

I would do a complete blood count to rule out infection and check the platelet levels. I would do a liver function test focusing on the serum alanine aminotransferase and aspartate aminotransferase levels. Kidney function tests rule out an acute kidney injury and helps check the uric acid levels (Khaliq, et al, 2018). Urinalysis helps to check for proteins. I would do an obstetrics ultrasound to check for fetal well-being.

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Treatment Plan

Pharmacological

• Patient to continue with methyldopa and metformin
• Paracetamol 1g per oral three times a day for the headache
• Esomeprazole 80mg IV three times a day for the epigastric pain, heartburn, and reflux.
• Nosic 1tablet three times a day for nausea
• Labetalol 20mg IV stat over 2mins then monitor the blood pressure.

Non-Pharmacological Treatment

• Bed rest and close monitoring of the vitals (blood pressure and central venous pressure)
• Restricted fluids intake
• Lower limb elevation helps to reduce peripheral edema.

References

Battarbee, A. N., Sinkey, R. G., Harper, L. M., Oparil, S., & Tita, A. T. (2020). Chronic hypertension in pregnancy. American journal of obstetrics and gynecology, 222(6), 532-541.

Khaliq, O. P., Konoshita, T., Moodley, J., & Naicker, T. (2018). The role of uric acid in preeclampsia: is uric acid a causative factor or a sign of preeclampsia?. Current hypertension reports, 20(9), 1-9.

Rana, S., Lemoine, E., Granger, J. P., & Karumanchi, S. A. (2019). Preeclampsia: pathophysiology, challenges, and perspectives. Circulation research, 124(7), 1094-1112. Focused SOAP-Hypertension in Pregnancy Paper