Summary of evaluation

Present materials: two H&Ps, ten pharm cards and one article

In site evaluation, I present a patient with preeclampsia. Patient is a 29 years old female G1P0000, last menstrual period 8/18/18, estimated date of delivery 5/25/19, at estimated gestational age of 36 weeks and 4days with no past medical history complains of elevated blood pressure for 2 days. Positive fetal movements, no vaginal leaking or bleeding. Mild headache, no visual changes, edema, abdominal pain, or fever. Negative physical exam, normal ultrasound, trace protein in the urine. This case allows me to review diagnose criteria of preeclampsia, and also learn how to manage preeclampsia in the clinical setting. For this case, patient is admitted to labor and delivery department unit for monitoring, and betamethasone is given to mature fetal lungs. If any symptoms of preeclampsia coming up, will need to deliver the baby immediately. I also find an article that investigate efficacy and safety of aspirin use in preventing preeclampsia, and the randomized controlled study concludes that aspirin group patients have fewer incidence of preeclampsia.

For the second case, I write up for threatened abortion presentation. Patient is a 31 years old female with no past medical history complains of spotting and LLQ pain for 2 weeks. 2-3 episodes of spotting, LLQ pain is mild, cramping, intermittent, no radiation. Denies fever, chills, headache, dizziness, nausea, or vomiting. With negative physical examination findings, cervical os closed, no active vaginal bleeding, positive pregnancy test, and bedside sonogram shows gestational sac with yolk sac.

Feedback received

Prof. Stephens gave feedback for my H&Ps. In the assessment part, should include most likely diagnose or the diagnose that I will work on for the plan part. For example, for the first case, preeclampsia, I should indicate that patient’s presentations and lab results are most consist with diagnose of preeclampsia, and then show the steps of management and patient education about preeclampsia.

Need to improve:

• For the differential diagnoses, need to consider more aspects, thinking broadly, not just for ob/gyn diagnoses. Because pregnant patients can also have other issues which are not related to their pregnancy
• For the plan part, and order the diagnose imaging, need to indicate the date of the test

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