Response to Susan

PLEASE RESPOND TO THIS DISCUSSION POST OF MY COLLEAGUE, ALSO ADD TO THE RESPONSE THE DIFFIRENTIAL DIAGNOSIS TO CONSIDER CHRONIC HYPERTENSION SINCE SHE HAS HISTORY OF HYPERTENSION PRIOR TO PREGNANCY.

 

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Patient Information:

KB 36-year-old African American.

S.

CC Headache

HPI: KB 36-year-old African American female presents in office due to headache with elevated blood pressure. The patient is currently 30 5/7 weeks pregnant with a history of Pregnancy-induced hypertension and preeclampsia in the first trimester. Labs have been normal in pregnancy. The patient has been non-compliant with labetalol because she does not want to take anything to harm the baby. The patient is G1 P0. The patient denies blurred vision, nausea, or epigastric pain. Fetal movement is normal. Slight edema to extremities. Pregnancy weight gain 17 lbs. No distress noted.

Location: head

Onset unk

Character: unk

Associated signs and symptoms: No blurred vision or nausea

Timing: unk

Exacerbating/relieving factors: unk

Severity: unk

Current Medications Labetalol unk dosage. Does not take regularly. Prenatal vitamins

Allergies:unk allergies..

PMHx

Hypertension,

Soc & Substance Hx: unk

Family hx: unk

Surgical Hxunk.

Mental Hxunk.

Violence Hx: unk

Reproductive Hx: P0 G1 patient conceived through IVF

ROS:

GENERAL: No weight loss, fever, chills, weakness, or fatigue.

HEENT: Eyes: No visual loss, blurred vision, double vision, or yellow sclerae. Ears, Nose, Throat: No hearing loss, sneezing, congestion, runny nose, or sore throat.

SKIN: No rash or itching.

CARDIOVASCULAR: slight edema to extremities. No chest pain, chest pressure, or chest discomfort. No palpitations.

RESPIRATORY: No shortness of breath, cough, or sputum.

GASTROINTESTINAL: No anorexia, nausea, vomiting, or diarrhea. No abdominal pain or blood.

GENITOURINARY: Burning on urination. Pregnancy30 5/7 weeks.

NEUROLOGICAL: No headache, dizziness, syncope, paralysis, ataxia, numbness, or tingling in the extremities. No change in bowel or bladder control.

MUSCULOSKELETAL: No muscle pain, back pain, joint pain, or stiffness.

HEMATOLOGIC: No anemia, bleeding, or bruisng.

LYMPHATICS: No enlarged nodes. No history of splenectomy.

PSYCHIATRIC: No history of depression or anxiety.

ENDOCRINOLOGIC: No reports of sweating or cold or heat intolerance. No polyuria or polydipsia.

REPRODUCTIVE: Patient is 30 weeks pregnant. Not sexually active.

ALLERGIES: No history of asthma, hives, eczema, or rhinitis.

O.

Physical exam:

Vitals signs: 162/90 p-82 R-16 BMI 25.1 temp- 98.2

Cardiovascular: S1/S2 clear, no murmurs, no edema, pulses 2+ all extremities, CRT <2sec

 Respiratory: Lungs clear to auscultation, no cough, equal chest expansion

Gastrointestinal: normal for pregnancy measuring 31cm, non-tender, no guarding, + palpable inguinal lymph node on R, bowel sounds present

Genitourinary: Normal no bleeding or discharge. No burning or frequency.

 Breast exam- bilateral breasts are soft, non-tender, no palpable masses, no discharge

Integumentary: No visible rashes to hands or feet, skin is warm/dry/intact, no other lesions Neurologic: Alert & oriented, cooperative, appropriate

Diagnostic results: CBC, CMP, Thyroid panel. 24 hour Urine protein /creatine ratio, Ultrasound.Fetal monitoring. Lab results.

WBC

10.92

RBC

3.63

Hgb

10.4

Hct

32,5

Plts

238

Glucose

98

Sodium

144

Potassium

3.9

BUN

9

Creatinine

0.64

ALT (SGPT)

96

AST

75

Alk Phos

187

aPTT

26.9

Fibrinogen

650

Uric acid

3

Urine protein/Creatinine ratio

0.11

A.

Differential Diagnoses

  1. Preeclampsia: 014.00 Mild Preeclampsia can cause elevated liver enzyme and may also leave you with liver swelling. It is among the most serious liver problems in pregnancy, and it usually affects you during the third trimester of pregnancy. The most common symptom is elevated blood pressure. When left untreated, preeclampsia results in stroke, seizures, and even death of the mother or baby. It is therefore important to seek immediate medical attention to prevent liver damage, (newhealthadvisor.org., 2021). Patient does have many risk factors age, history of hypertension, first pregnancy.
  2. HELLP Syndrome 014.22  Among many liver problems in pregnancy, one serious disorder is HELLP syndrome. In this condition, you develop anemia, low platelets, and elevated liver enzymes. You are more likely to develop it during your third trimester and it can also develop postpartum. It can lead to several complications and result in liver damage as well as kidney failure. Bleeding problems, stroke, and death are other possible consequences (newhealthedvisor.org., 2021). This may be progression of patients status patients platelet count at this time is normal.
  3. Chronic hypertension I10 blood pressure is the pressure of blood pushing against the walls of your arteries. Arteries carry blood from your heart to other parts of your body. Blood pressure normally rises and falls throughout the day, but it can damage your heart and cause health problems if it stays high for a long time. Hypertension, also called high blood pressure, is blood pressure that is higher than normal.(cdc.org., 2020)

 

P.

Diagnostic studies

Us, fetal monitoring. CBC, liver panel CMP, UA 24 hour protein /creatinine ratio.

Therapeutic intervention’s: Hydralazine 5 mg IVP repeat in 30 min if no change

                                            Nifedipine 10 mg po. With fetal monitoring

Education: Educating patients on the need to take oral blood pressure medication as directed by the primary physician is important to help prevent hypertensive emergencies. Related to preeclampsia. Reduce sodium diet. Seek medical attention immediately if shortness of breath, severe headache, upper rt quad pain. And visual changes. Advise patient to wear seatbelt,

Follow up: cbc, liver enzymes, creatinine  UA once weekly. Blood pressure check 2 times a week. Amniotic fluid q week/

Reflection: In reflection of case study I would like to know additional information about her symptoms, for example: has she had similar headaches and does anything make the headaches better. How long does it last. If she has had abdominal pain. How many years did she take hctz, Allergies to medication or foods. Family history.

 It is important to continue with medications that were prepregnancy, such as hypertension medication. The FDA has created guidelines for drug companies to follow in regards to labeling medications and their affects on reproduction and pregnancy. According to these guidelines a category C medication is one in which the risk to the pregnancy cannot be ruled out. For medications in this category, adequate, well-controlled human studies are lacking, and animal studies have shown a risk to the fetus or are lacking as well, (Morrison, n.d.).

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