RT4-OBGYN H&P

RT4-OBGYN H&P1 – Labor and delivery department

Jinjin Lin

 

Identification:

Patient’s name: Ms. H

DOB: 29 years old

Gender: female

Race: Hispanic

Location: Woodhull medical center, labor and delivery department, Brooklyn, NY

Date and Time: 5/2/2019, 10 pm

Informant: self, reliable

CC: “My blood pressure is high” x 2 days

HPI: A 29 years old Hispanic 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 reported past medical history presents to labor and delivery department complains of elevated blood pressure for 2 days. Reports blood pressure measured at home with reading of 142/94 yesterday and two blood pressure readings of 147/86 and 128/84 in antenatal testing unit today. Reports positive fetal movements, denies vaginal leaking or bleeding. Admits mild headache, located at frontal lobe with pressure property, comes and goes, 2/10, no radiation. Denies visual changes, edema, abdominal pain, pelvic pain, fever, chills, nausea, or vomiting. Prenatal care at Woodhull hospital from 10/18 to 5/2/19 x 14 visits with midwifes.

Differential Diagnosis:

  • Preeclampsia: elevated blood pressure at 2 separated occasions at least 6 hours apart, and headache is common symptom for preeclampsia, risk factor of primiparity
  • Gestational hypertension: hypertension after 20 weeks gestation, risk factors of nulligravidity and Hispanic ethnicity

PMH:

Patient denies any past medical history.

Past Surgical History:

Patient denies any past surgical history.

Medications:

Multivitamin 1 tablet PO QD

Allergies:

Patient denies any drug, foods, or environment allergies.

Family History:

Father- 62, alive and well

Mother- 59, alive and well

Social History:

Ms. H lives with her husband in Brooklyn NY. She is a housewife, and sleeps well with average 9 hours sleep per night. Sexually inactive, denies STDs. Denies recent travel, nicotine use, alcohol consumptions, past or present illicit drug use.

ROS:

General: Patient denies fever, chills, loss of appetite, generalized weakness

HEENT: Patient reports mild headache, and denies visual changes, swelling or lumps in the neck

Skin: Patient denies any changes of texture, excessive dryness or sweating, discolorations, rashes, pruritus

Breast: Patient denies lumps, nipple discharge, pain.

Pulmonary System: Patient denies SOB, DOE, cough, wheezing, hemoptysis, cyanosis

Cardiovascular System: Patient denies chest pain, palpitations, edema, syncope

Gastrointestinal System: Patient denies changes in appetite, nausea, vomiting, dysphagia, diarrhea, jaundice, change in bowel habits, constipation, rectal bleeding

Genitourinary System: Patient denies dysuria, changes in frequency, nocturia, urgency, oliguria, polyuria, or incontinence

Menstrual and Obstetrical: Patient last normal period on 8/18/18, the time of menarche is 11 years old, her menstrual cycle is 28 days with medium flow without clots. Patient denies postcoital bleeding, dyspareunia.

Nervous System: Patient reports mild headache, and denies seizures, loss of consciousness, change in cognition, mental status, memory, or weakness

Musculoskeletal System: Patient denies muscle or joint pain, deformity or swelling, redness, arthritis

Endocrine System: Patient denies polyuria, polydipsia, polyphagia, heat or cold intolerance or goiter

Psychiatric: Patient denies depression or anxiety

 

Physical Examination:

General: 29 years old pregnant female is well-groomed, alert and orientated to person, place, and time. Cooperative and well-nourished, not in acute distress.

Vital Signs:

BP (lying): 142/90

HR: 89BMP, regular

RR: 17, not labored

Temp: 96.6 F oral

O2 sat: 99% room air

Height: 5ft 4in  Weight: 149lb

Skin: Warm and moist, no lesions or no scars

Nails: No clubbing, capillary refill <2 seconds throughout.

Head: Normocephalic and atraumatic, nontender to palpation

Eyes: PERRLA, EOMs full with no nystagmus, visual acuity intact

Oral cavity:  Pink, moist, no lesions or discharge

Neck: Supple, normal range of motion

Thyroid: Nontender, no palpable masses, no thyromegaly, no bruits

Chest: Symmetrical, lat to AP diameter 2:1, no deformities, no trauma. Respirations unlabored. Nontender to palpation

Lungs: Clear to auscultation and percussion bilaterally. No wheezing, crackles, rales

Heart: S1, S2 without murmur, no gallops, S3 or S4

Abdomen: Soft, non-tender. Bowel sounds in all 4 quadrants and gravid uterus. No CVAT bilaterally

Uterine size: Size equals dates

Neurological: Alert and oriented to person, place and time. Memory and attention intact

Extremities: No soft tissue swelling or erythema, nontender bilaterally. No evidence of DVT seen on physical exam

OB examination:

Membranes status: intact

Cervical exam:

Dilation=0

Effacement (%)=0

Station= -3

Cervical Position=0

Cervical Consistency=1

Bishop Score=1

Nonstress test:

Fetal heart rate: present

Baseline Rate: 150 bpm

Variability: Moderate (Between 6 and 25 BPM)

Decelerations: None

Accelerations: Yes

Uterine activity:

Uterine contractions: present

Mode: toco, palpation

Contraction frequency: irregular

Contraction duration: 20-40 sec

Contraction quality: mild

Resting tone palpated: soft

Laboratory:

CMP:

BUN=8

Sodium=142

Potassium=3.9

CO2=20 mmol/L (low)

Glucose=79

Creatinine=0.94

Total protein=6.2

Albumin=3.3

Total bilirubin=0.2

ALK PHOS=122

AST=6

ALT=4

Anion gap=13

eGFR >60

CBC:

WBC =6.9

RBC=4.16 (slightly low)

HGB=11.3 (slightly low)

HCT=35.7 (slightly low)

MCV= 90.2

RDW=13.2

PLT= 130

Neutrophil% =71.8

Lymphocyte%= 20.2

Monocyte%=4.0

Eosinophil%= 3.6

Basophil%=0.3

POC glucose: 78 mg/dL

Urine analysis:

PH=6.9

Color=yellow

Appearance=clear

Bilirubin=negative

Ketones=negative

Specific gravity=1.010

Blood urine= negative

Protein urine=trace

Nitrate= negative

Leukocyte esterase= negative

WBC=0-2

RBC=rare

Bacteria=negative

Differential Diagnosis:

  • Preeclampsia: elevated blood pressure at 2 separated occasions, headache is common symptom for preeclampsia, risk factor of primiparity, positive protein in urine
  • Gestational hypertension
  • Eclampsia: elevated blood pressure, protein in the urine. If preeclampsia left untreated, may progress to eclampsia

Assessment: 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.

Plan:

  • Preeclampsia without severe features, admit to labor and delivery unit for monitoring.

Continue electronic fetal monitoring and maternal vital signs monitoring.

Patient for delivery if symptoms occur otherwise will proceed with delivery at 37 weeks.

Mode of delivery: vaginal unless obstetrical or fetal indications arise.

Official sonogram for weight in the morning.

Repeat CMP, CBC, UA in the morning.

  • Start betamethasone 12.5mg IM q24 hours x 2 doses.
  • Continue Multivitamin 1 tablet PO QD.
  • DVT prophylaxis with pneumatic compression stockings if confined to bed, ambulation if not.

 

ADD OB ultrasound done in the morning:

Pregnancy Location: Intrauterine

Fetal Heart Rate(bpm): 149

Cardiac Activity: Observed

Presentation: Vertex

Placenta: Left Grade 2 No Previa

Amniotic fluid index: 13.1

Gestational age:

Best: 36w 4d   Det. By:  LMP (08/18/18)    EDD: 05/25/19

Anatomy:

Stomach= Normal appearance

Kidneys=Normal appearance

Bladder=Normal appearance

Estimated fetal weight: 2916 gm 6 lb 12 oz  65 %

Comments: EFW is 2916 gms which falls at 65 %. Interval fetal growth is appropriate. A biophysical profile of 8/8 was identified. There was evidence of normal amniotic fluid volume, fetal gross body movements, fetal tone, and 30 seconds of sustained fetal breathing within 30 minutes

 

Patient education:

  • Your signs and symptoms of high blood pressure and headache, and the urine test we did show some protein in the urine, all these suggest preeclampsia. Preeclampsia is a pregnancy complication, it will have high blood pressure and some signs of damage to other organ system, most often will be the liver and kidneys. We want to keep you in the labor and delivery unit to keep monitoring baby and your blood pressure, and wait for official ultrasound and repeat blood tests for liver and kidney functions and platelet in the morning.
  • The management of preeclampsia depends on the gestational age and whether you have severe features of the disease are present. As so far, we do not see severe features. The only cure for preeclampsia is delivery of the baby. Because the preeclampsia developed before term, which is less than 37 weeks, and there are no severe features seen, we will wait to delivery at 37 weeks to allow the baby more time to grow and mature. However, we want you to understand that if severe features of preeclampsia developed, like changes in visions, labs show low platelets and abnormal liver and kidney functions, or problems of baby with restricted growth, reduced blood flow to baby, we will deliver the baby immediately. Let’s say, if we need to deliver the baby before 37 weeks, baby will be premature, and will be at risk of breathing problems because lungs may not be fully developed yet. So, we will give you 2 steroids injections, called betamethasone 12.5mg, to speed up baby’s lung development. The two injections will be given 24 hours apart.
  • The method of delivery either vaginal or cesarean birth, depends on the position of the baby, baby’s condition, the dilation and thinning of the cervix. We will know more about these after we do an ultrasound in the morning.
  • Please let the nurse know that if you develop symptoms of severe headache; changes in visions, like you cannot see things clearly, loss of vision, or sensitive to light; upper abdominal pain, nausea, vomiting or feeling of swelling of the legs and face.
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