Routine Prenatal Appointment
Hannah is 38 years old, G1P0, 32 weeks EGA and comes to you for her routine prenatal appointment. Her BP is 156/96 and her urine has 2+ protein. She complains of having a headache that will not go away and just not feeling “right” for the past 7 days.
Write a brief SOAP note regarding this patient. Make sure to include your answers to these questions in your SOAP note.
Subjective:
What other relevant questions should you ask regarding the HPI?
O- when did you started to experience the headaches?, A couple weeks ago
L- What side of your head is the pain located?, In the front of my head both sides
D- How long does the headache lasts?, For a couple hours
C- How does the headache feels?, Throbbing, aching, pressure or pulsating? Pulsating
A- What makes the headache better or worse?, When I lay down in my bed the headaches tend to get worst. Tylenol usually helps
R- Does the headache radiates to your neck or any other part of your head? No, it does not radiate
T- At what time during the day do you experience the headaches? Usually in the afternoon
S- Scale 0-10 what number will you give the headache? 7
- Have you hurt your head recently? No
- Are you drinking enough water?
- Any changes in your vision? No
- Any changes in your mental status? No
- Any recent seizure activity? No
- Have you change anything in your diet? I have been craving a lot of food containing carbohydrates
What other medical history questions should you ask?
- History of hypertension?
- History of heart problems in her family?
- Recent hospitalization
What other OB history questions should you ask?
Objective:
Describe the appropriate physical assessment that needs to be included in this visit.
BMI
Vision checks for (scotoma, papilledema, vascular spasms, arteriovenous nicking)
Neuro assessment (headaches, CNS involvement, seizures)
Abdomen RUQ pain (liver involvement)
Musculoskeletal -Deep tendon reflex
Skin assessment (bruising)
Mouth (bleeding gums)
Respiratory (lung sounds for pulmonary edema, SOB)
Vascular- presence of worsening edema
Explain what test(s) you will order and perform and discuss your rationale for ordering and performing each test.
A CBC will be ordered in this case patient signs and symptoms suggest preeclampsia. Patients with preeclampsia usually have a platelet count of <100,000/microliter putting the patient at high risk of bleeding. Serum creatinine level, in patients with preeclampsia creatinine levels are >1.1mg/dl. Liver chemistry, elevated liver enzymes is usually seen in patients with this condition which can lead to other complications. Quantitative urinary protein. Fetal ultrasound to evaluate amniotic fluid volume and estimate fetal weight due to the high risk of oligohydramnios and fetal growth restrictions in patients with preeclampsia. If patients’ tests are negative for preeclampsia other test will be ordered depending on the patient presenting symptoms and objective data. Also, will like to include a chest x-ray if pulmonary edema is suspected.
Assessment/ Diagnosis:
What is your diagnosis?
Mild to Moderate Preeclampsia (ICD-10: O14.0)
Preeclampsia is a multisystem disorder mostly characterized by hypertension and proteinuria. Patients usually develop preeclampsia after 20 weeks of gestation or in the postpartum period. Preeclampsia can also include other organs including liver, the CNS system, ophthalmic, hematological, respiratory and the inflammatory system (August & Sibai, 2024). Patients with preeclampsia usually present with BP >140/90, proteinuria, headache, pulmonary edema, and visual disturbance. In this case patient is 32 weeks EGA with a BP 156/96, constant headache and 2+ proteinuria suggesting evaluation for preeclampsia. After reviewing patient signs and symptoms and using the ACOG preeclampsia criteria, I was able to diagnose patient with preeclampsia
Include any appropriate differential diagnosis.
Gestational hypertension (ICD-10: O13.3)
Liver disease (ICD-10: K76.9)
Plan:
Do you feel that this can be managed via outpatient? Why? How will you manage this?
Yes, this patient can be managed in the outpatient setting. Patient is not exhibiting any signs or symptoms that will prompt an emergency referral. Patient can be managed in the clinic, if patient conditions start to deteriorate, abnormal lab results or increased in BP. Patient will be referred to the emergency department. Patients with severe preeclampsia are at risk of liver failure, renal failure, DIC, CNS abnormalities and fetal complications (Jordan et al., 2018).
Do you feel that should be managed inpatient? Why? What do you think will be done in patient?
No, I don’t feel this should be manage inpatient unless patient starts to present other symptoms or unable to get patient blood pressure under control.
If you chose to manage outpatient- explain the medication regimen, testing, and follow up that needs to be done.
If you chose to manage inpatient- explain what medication and testing will be done in patient, and how will you continue management once patient is discharged. What medication and testing do you need to continue for this patient?
What patient education is important to include for this patient?
Explain complications that can occur if patient does not comply with treatment regimen.
Provide evidence from the research to support your decision-making.
Raza, S. K., & Raza, S. (2023, June 26). Postpartum psychosis. StatPearls – NCBI Bookshelf. https://www.ncbi.nlm.nih.gov/books/NBK544304/#:~:text=Once%20organic%20causes%20have%20been,%2C%20quetiapine%2C%20olanzapine%2C%20etc.
Berens, P. (2024, May 28). Overview of the postpartum period: Disorders and complications. UpToDate. https://www.uptodate.com/contents/overview-of-the-postpartum-period-disorders-and-complications?search=Post%20partum%20hemorrhage%20signs%20and%20symptoms&source=search_result&selectedTitle=1%7E150&usage_type=default&display_rank=1
August, P., & Sibai, B. (2024, October). Preeclampsia: Clinical features and diagnosis. UpToDate. https://www.uptodate.com/contents/preeclampsia-clinical-features-and-diagnosis?search=preeclampsia%20diagnosis&source=search_result&selectedTitle=1%7E150&usage_type=default&display_rank=1#H1
Jordan, R. G., Farley, C. L., & Grace, K. T. (2018). Prenatal and postnatal care: A Woman-Centered Approach. John Wiley & Sons.