Description POST 1 Subjective CC: “I’m 32 weeks pregnant and have had a headache for the past week. I am not feeling right” HPI: A 38 year old (G1P0) presents in office today with a complaint of headache and reports “I am not feeling right.” Patient states headache began 7 days ago and has remained constant (pain rated 7/10). She reports that her headache is generalized and states she took Tylenol several times, but it did not improve symptoms. In addition to the headache, the patient states she does “feel right” but cannot pinpoint to a specific symptom but rather reports a general uneasy feeling that began around 7 days ago as well. She reports that she checked her BP at home and it was 148/96 at 7 am this morning. Patient states that she keeps a daily log of BP recordings and that up until recently her BP had been well-controlled (“around 120/70”). She now reports that her BP has consistently been high for 5 days. She states she is anxious about complications with her pregnancy. She has no other complaints at this time. Medications: Nifedipine ER 90 mg PO once daily (August, 2024) Allergies: No known allergies LMP: 8/10/2023 Gyn/OB history: G1P0, RH+. Normal pap (2023). STI negative. Prenatal routine screenings WNL. Menarche age 12. Denies a PMH: Chronic HTN Surgical Hx: No surgical history. Major trauma: No history of major trauma Family Hx: Mother- HTN, DM II Father- Obesity, DM II Social Hx: Denies alcohol consumption & illicit drug use. Currently in monogamous relationship with husband of 5 years. Sexual partner history: 4. Patient works as a kindergarten daycare teacher. Education: college graduate ROS General: Reports feeling generally unwell. Denies fevers and chills. Eyes: Denies vision changes, vision loss, visual disturbances. ENT: Denies hearing loss, changes in hearing. Denies nose bleeds, nasal drainage/congestion. Denies sore throat, difficulty swallowing. Cardiovascular: Reports elevated BP for several days. Denies chest pain, tightness. Denies palpitations. Respiratory: Denies cough, coughing up blood/phlegm production. GI: Denies nausea/vomiting. Denies abdominal pain. Denies diarrhea/constipation. Musculoskeletal: Denies muscle/joint pain. Denies recent injury. Endocrine: Denies frequent thirst/hunger. Denies cold/hot intolerance. Hematopoietic/Lymphatic: Denies bleeding easily. Denies bruising quickly. Denies lymph node swelling. Neuro: Reports constant generalized headache for past 7 days. Denies loss of consciousness, lightheadedness, and dizziness. GU/GYN: Denies painful urination. Denies frequent urination. Denies flank pain. Denies discharge and vaginal bleeding. Denies leaking of fluid. Denies absence/slowing of fetal movement. Denies suprapubic pain. Denies contractions. Psych: Reports anxiety over recent symptoms and potential complications. Denies depression. Objective Data VS BP: 147/98 HR: 101 RR: 16 Temp: 97.9F Spo2:99% RA Wt: 120 lbs Ht: 5’3” BMI 20 (weight gain WNL) Physical Exam: Const./General: Elevated BP of 147/98 (other VS WNL). Alert, appears very anxious. No acute distress. HEENT: Atraumatic. White sclerae, PERRLA. TMs clear, pearly gray. Nares patent, no drainage noted. Mucosa pink and moist with no visible lesions. Good dentition. Tongue/uvula midline. Neck: Supple. No lymphadenopathy or JVD. Thyroid palpated normal in size. Respiratory: Unlabored breathing. CTAB. Chest rise equal and symmetric. No adventitious lung sounds. Cardiovascular: S1, S2 without murmurs or gallops noted. GI: Normoactive bowel sounds. No hepatosplenomegaly on exam. No abdominal tenderness, masses, or distension noted. Integumentary: Skim warm, dry, and intact. No lesions or rashes noted. No bruises noted. Extremities: No edema. Pulses +2 radial/pedal. Neuro: CN intact II-XII. DTRs intact, +2 bilaterally. Sensation intact. No motor or sensory deficits noted. Psych: A&O x3. Appropriate behaviors throughout interview and examination. Other: FHR 150 BPM by doppler u/s, regular rhythm --------------------- POC testing: Urine dipstick, Fetal u/s, umbilical artery doppler velocimetry w/ amniotic fluid assessment (Walker & Morley, 2023) Assessment/ Diagnosis Working diagnosis: Chronic hypertension with superimposed preeclampsia (ICD-10: O11) Differential diagnoses: Dehydration (ICD-10: E86.0) Nephrotic syndrome (ICD-10: N04.8) Diagnoses rationale: I selected pre-eclampsia superimposed on chronic hypertension as my working diagnosis because the patient meets diagnostic criteria for this condition (SBP greater than 140 and DBP greater than 90 for several days and dipstick urine reading 3+proteinuria). The patient is a good historian with a well-documented history of self-reported (and in office) normal BP readings. Therefore, a sudden increase in BP and proteinuria combined with intractable headache raise a red flag for this condition making this diagnosis highly probable. In addition, her age and nulliparous status make her more at risk for superimposed pre-eclampsia (August & Sibai, 2024). I selected dehydration as a differential diagnosis for this patient because of her reported headache and elevated HR. Dehydration is also described as a benign cause of proteinuria which is a finding supporting this diagnosis (Haider & Aslam, 2023). Dehydration is not likely, however, as it does not explain the patient’s recent onset of hypertension. Nephrotic syndrome was selected as another differential diagnosis because of the presence of proteinuria. However, this diagnosis is also unlikely as hypoalbuminemia and peripheral edema are not present (Pepper & Connolly, 2021). In addition, it does not explain the patients BP or headache. Plan Diagnostic tests Labs: CBC, CMP, LFTs (LDH if abnormal LFTs), PT/PTT & fibrinogen, 24 hour urine CBC- to check disease progression & to look for decreased platelet count CMP- to monitor overall health status LFTs- to check transaminase levels which is part of diagnostic criteria for HELLP. Creatinine that is elevated may signal renal disease. PT/PTT & Fibrinogen- to assess risk for spinal/epidural and bleed risk. 24 hour urine- to obtain accurate reading of urinary excretion of protein (greater or = to 300 in 24 hours proves diagnosis). (Walker & Morley, 2023). POCT: Urine dipstick, fetal u/s, umbilical artery doppler velocimetry w/ amniotic fluid assessment in office today Urine dipstick [Result: 3+ proteinuria] Fetal Ultrasound [Result: no abnormalities/normal fetal assessment] Umbilical artery doppler velocimetry w/ amniotic fluid assessment [Result: Normal] (Walker & Morley, 2023). Treatment Start Labetalol 100 mg PO BID Continue Nifedipine ER 90 mg PO once daily (Walker & Morley, 2023) Referrals Admit to hospital for monitoring and further management No outpatient referrals at this time Education Importance/reasoning for recommending hospital admission to treat/ monitor BP and monitor progression of pre-eclampsia/ other complications. Explain need to make decision regarding delivery. Patient must understand how delivery is the best treatment option (ideally at 37 weeks or greater but sooner if needed). Dietary and fluid intake considerations (sodium/fluid restriction) Postpartum monitoring expectations and risks (fluid overload). (Walker, & Morley, 2023) Health Maintenance Up to date. Follow up Follow up within 48 hours after discharge. POST 2 Subjective: CC: “I am here for my prenatal care” HPI: 31-year-old female is here for her routine prenatal visit. She does not have any questions or concerns for this visit. Based on her LMP, which is consistent with her 7-week ultrasound, her gestational age is 24 0/7, with an EDC of July 16, 2024. Her pregnancy has been uncomplicated so far. She has completed all of her initial prenatal labs which were within normal limits, including AB+, rubella immune. She completed her NT ultrasound and 20-week anatomical survey with normal results, the placenta is anterior without previa, fetal position is vertical lie. She completed her NIPT and MSAFP genetic screenings, and the results were negative. She is having another girl! Her carrier screenings for CF, SMA, and Fragile X were negative. She reports her nausea has improved, and she no longer has food aversion. She has gained 4 pounds since her last visit a month ago, and her overall weight gain this pregnancy has been 10 pounds. She does not have any travel plans. LMP: 10/10/2023. Menses were regular every 28-30 days before conception. Gyn/OB history: Menarche age 12. G2P1001 at 24 0/7 gestation. Hx of NSVD at 40 3/7 on 3/4/2021. Prior pregnancy was complicated by GDMA1, but blood sugars were well controlled and did not require medication. She was on COC pills prior to her first pregnancy but has not been on any contraception since delivery. She breastfed exclusively for the first 9 months, then weaned to formula when she returned to work. No complications from breastfeeding and plans to BF again. No hx of STI. Medications: Prenatal vitamins with minerals gummy once daily Allergies: NKA Past medical hx: Tonsillectomy age 5, GDMA1 with prior pregnancy and completed 12-week postpartum 2hr oral GTT. Family hx: Mother has type 2 diabetes, Father is alive and healthy. No siblings. No family history of cancers or genetic abnormalities. Social hx: Lives with husband and 3-year-old daughter. Mutually long-term monogamous relationship. Works part-time. She has a good network of friends and family for support. She does not use tobacco, smoke, drink alcohol, or use recreational drugs. She swims once a week for exercise. ROS: Constitutional: denies fever or weight change, reports increased appetite and minimal fatigue HEENT: denies any vision or hearing problems, nasal congestion, rhinorrhea, sore throat Cardiovascular: denies chest pain, pressure or palpitations with rest or activity Respiratory: denies cough, shortness of breath, or recent respiratory illness GI/GU: denies abdominal pain or changes in bowel habits, denies nausea, vomiting. Denies dysuria or blood in the urine. GYN: denies vaginal bleeding or spotting. Reports a slight increase in her normal vaginal discharge. Denies breast pain. Skin: denies rash or swelling, reports stretch marks Endocrine: denies polyuria, reports mild polydipsia Musculoskeletal: denies joint pain, stiffness or decreased range of motion Neurological: denies headache or dizziness/lightheadedness Psychological: denies depression or anxiety Objective: VS- BP 118/78, P 68, RR 18, T 98.7F, WT 145lbs, HT 65in, BMI 24 Constitutional: Appropriate appearance, not in acute distress. HEENT: normocephalic, atraumatic. Conjunctiva normal. PERRL. Neck supple. No thyroid enlargement or nodules. Cardiovascular: S1, S2 present. Normal rate and rhythm. Respiratory: LCTA bilaterally, effort normal Abdomen: gravid, soft, non-tender, active bowel sounds x 4 GYN: normally developed genitalia, no lesions or ulcers. A moderate amount of vaginal discharge is thin and clear. No erythema or excoriation note. Cervix is multiparous, slightly bluish, and os is closed. FHT: 148 bpm Fundal Height: 25cm Breasts: no masses, lumps, or lesions. No nipple discharge. Skin: minimal pink striae noted bilaterally around gravid abdomen, normal turgor, no extremity edema. Musculoskeletal: normal movement of all joints observed Neurological: alert and oriented x 3. No focal deficits Psychological: appropriate affect, thought, and behavior normal POCT and Lab Results Urinalysis dipstick, POC - negative for protein and glucose 1hr oral GTT completed 3/19/2024 - 156mg/dL (High) Assessment/ Diagnosis: Working Dx: Z34.82 - Encounter for supervision of other normal pregnancy, second trimester Z3A.24 - 24 weeks gestation of pregnancy Z86.32 - History of gestational diabetes R73.02 - Impaired glucose tolerance (oral) - pertinent positive includes mild polydipsia, elevated 1hr oral GTT greater than 140mg/dL but less than 180mg/dL requiring 3hr oral GTT Differential Dx: O24.419 - Gestational diabetes mellitus in pregnancy, unspecified control - pertinent positive includes mild polydipsia, hx of GDMA1, and elevated 1hr oral GTT; pertinent negative includes automatic diagnosis of GDM with 1hr oral GTT >180mg/dL Plan: Diagnostic Tests: 3hr oral GTT (for diagnostic or to rule out GDM), repeat CBC w/o differential (to check for anemia in the second trimester), repeat RPR (routine 2nd-trimester screening recommended for all women) Treatment: This will depend on the test results. If the 3hr oral GTT comes back with two or more abnormal values, we will diagnose you with GDM and start the workup for evaluation and management. If the CBC returns with low hemoglobin and hematocrit levels, we will discuss starting iron supplements and nutritious food options. If the RPR syphilis test returns positive, we will follow up with a confirmatory treponemal test before treating with Benzathine penicillin G (Jordan et al., 2018). Patient Education: Gestational diabetes (GDM) is a result of elevated blood sugar levels and insulin resistance during pregnancy. If undiagnosed or untreated, it can cause complications to the mom and baby during pregnancy which include fetal anomalies, preeclampsia, fetal demise, macrosomia or large for gestational age baby, neonatal hypoglycemia, hyperbilirubinemia, or respiratory distress (ElSayed et al., 2023). Studies have even shown that children born to moms with GDM are at a higher risk for developing obesity, hypertension, and type 2 diabetes later in childhood (ElSayed et al., 2023). If your 3hr oral GTT comes back positive for GDM, your treatment would start with checking your blood sugar levels and making lifestyle modifications. If your blood sugar levels continue to be elevated and unmanaged, we will start medication. In your last pregnancy, you were GDMA1, meaning you were able to control your fasting blood sugar levels below 95mg/dL and your 1-hour postprandial blood sugar levels below 140mg/dL through eating nutritious foods, monitoring your carbohydrate intake, hydrating well, and exercising (Gestational diabetes mellitus, 2018). If you have GDM, we will prescribe you a glucometer and supplies for you to start keeping a daily log consisting of a fasting blood sugar level, and a 1 hour (postprandial) blood sugar level after breakfast, lunch and dinner, which will be reviewed weekly and help us determine if we need to start medication (Gestational diabetes mellitus, 2018). We will also place a referral for you to see a diabetic educator and nutritionist who will talk to you about the importance of monitoring your carbohydrate intake to reduce postprandial hyperglycemia and prevent hypoglycemia, and monitor caloric intake to prevent excessive weight gain (Gestational diabetes mellitus, 2018). They will also discuss incorporating more nutritious foods into your diet, which includes fruits, vegetables, legumes, whole grains, and healthy fats like nuts, seeds, and fish, while staying away from fried foods with saturated fats (ElSayed et al., 2023). If medication is indicated for unmanaged blood sugar levels, insulin is the preferred medication as it is well-studied and does not cross the placenta to affect your baby (Gestational diabetes mellitus, 2018). If there are indications when insulin is not an option depending on insurance coverage, a needle phobia or decreased compliance, the alternative medication would be oral metformin (Gestational diabetes mellitus, 2018). Metformin has been studied in pregnancy but it is not FDA-approved to treat GDM and it does cross the placenta reaching close to maternal levels in the fetus (Gestational diabetes mellitus, 2018). This means there could be an increased risk of neonatal hypoglycemia with metformin use (ElSayed et al., 2023). If your 3hr oral GTT comes back within normal range, or with only one abnormal value, you do not have GDM. This means we would continue your prenatal care as we have, and you will not need to check your blood sugar levels. It is important to keep in mind the healthy amount of weight gain in your pregnancy, which is between 25-35 pounds, and to continue to focus your attention on healthy lifestyle modifications such as eating a healthy, well-balanced diet, hydrating well with water, exercising daily or at least a few days a week with activities you enjoy to do and continuing your prenatal vitamin. Follow-Up: Please complete the fasting 3hr glucose tolerance test this week, along with the remaining blood tests. We will call you with the results. Please schedule your next prenatal visit in two weeks. As a reminder, always call the clinic right away if you experience any vaginal bleeding, leakage of fluids, contractions, or decreased fetal movements. Healthcare Maintenance: She is up-to-date on her childhood vaccines, including HPV series. She received her covid booster and influenza vaccine 4 months ago. Her last pap smear was 2.5 years ago and NIL.
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