case
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 3 rd 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
This study source was downloaded by 100000830772748 from CourseHero.com on 05-09-2022 09:19:30 GMT -05:00
https://www.coursehero.com/file/62247354/OBGYN-Tina-Sandler-Part3docx/
, 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
This study source was downloaded by 100000830772748 from CourseHero.com on 05-09-2022 09:19:30 GMT -05:00
https://www.coursehero.com/file/62247354/OBGYN-Tina-Sandler-Part3docx/
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 3 rd 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
This study source was downloaded by 100000830772748 from CourseHero.com on 05-09-2022 09:19:30 GMT -05:00
https://www.coursehero.com/file/62247354/OBGYN-Tina-Sandler-Part3docx/
, 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
This study source was downloaded by 100000830772748 from CourseHero.com on 05-09-2022 09:19:30 GMT -05:00
https://www.coursehero.com/file/62247354/OBGYN-Tina-Sandler-Part3docx/
