Assignment: Respond to the posts and explain how you might think differently about the types of diagnostic tests you would recommend and explain your reasoning.
Discussion post topic: Please POST your FOCUSED SOAP NOTE and post your primary diagnosis. Include the additional questions you would ask the patient and explain your reasons for asking the additional questions. Then, explain the types of symptoms you would ask. Be specific and provide examples. (Note: When asking questions, consider sociocultural factors that might influence your question decisions.)
Based on the preemptive diagnosis, explain which treatment options and diagnostic tests you might recommend. Use your Learning Resources and/or evidence from the literature to support your recommendations.
Case:
Case Study: Chronic Hypertension
Female was admitted to inpatient care with a diagnosis of chronic hypertension with severe features and started on Labetalol 200 mg po q 8 hours. She was monitored for 3 days and her BP stabilized at 130/78. Fetal testing was reassuring. She was discharged home on hospital day 3 on Labetalol and was to be seen twice weekly for BP checks, and was instructed to take her BP at home twice daily. Safety of medications was discussed in-depth with her. Signs/symptoms of PIH were reviewed with her. Two weeks later she had po nifedipine added. She subsequently delivered a healthy baby girl at 39 weeks gestation. She was discharged home on above medications (as she was breastfeeding) and continued meds for hypertension past her 6-week postpartum appointment. She was referred to her primary care provider for continuing care.
Purpose of this case study is to address the significantly different standards of labs and vital signs for pregnant patients.
Other student post: Episodic/Focused SOAP Note
Episodic/Focused SOAP Note
Patient Information:
Unknown, Unknown, Female, Unknown
S.
CC: Chronic Hypertension
HPI: Female was admitted to inpatient care with a diagnosis of chronic hypertension with severe features and started on Labetalol 200 mg PO q 8 hours. She was monitored for three days, and her BP stabilized at 130/78. Fetal testing was reassuring. She was discharged home on hospital day three on Labetalol and was to be seen twice weekly for BP checks; and was instructed to take her BP at home twice daily. The safety of medications was discussed in-depth with her. Signs/symptoms of PIH were reviewed with her. Two weeks later, she had PO nifedipine added. She subsequently delivered a healthy baby girl at 39 weeks gestation. She was discharged home on the above medications (as she was breastfeeding) and continued meds for hypertension past her 6-week postpartum appointment. She was referred to her primary care provider for continuing care.
Current Medications: Labetalol 200 mg PO q 8 hours and PO nifedipine (dose unknown)
Allergies: Not provided
PMH: Not provided
Soc & Substance Hx: Not provided
Fam Hx: Not provided
Surgical Hx: Not provided
Mental Hx: Not provided
Violence Hx: Not provided
Reproductive Hx: delivered a healthy baby girl at 39 weeks gestation, currently breastfeeding
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: No chest pain, chest pressure, or chest discomfort. No palpitations or edema.
RESPIRATORY: No shortness of breath, cough, or sputum.
GASTROINTESTINAL: No anorexia, nausea, vomiting, or diarrhea. No abdominal pain or blood.
GENITOURINARY: No burning on urination, delivered a healthy baby girl at 39 weeks gestation LMP: unknown
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 bruising.
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: Delivered a healthy baby girl at 39 weeks gestation, currently breastfeeding, No reports of vaginal discharge.
ALLERGIES: No history of asthma, hives, eczema, or rhinitis.
O.
Physical exam:
Vital signs: Not provided in the case study
General: Appears in clinic clean, well-groomed, and well-nourished
HEENT: No abnormalities were noted
Skin: Good turgor, no rashes, unusual bruising, or lesions noted
Cardiovascular: Regular sinus rhythms without murmur or gallop
Respiratory: Lungs clear to auscultation bilaterally.
Gastrointestinal: Abdomen is soft and non-tender. Active bowel sounds x4 quadrants.
Musculoskeletal: No swelling or edema was noted
Genitourinary: No abnormalities were noted
Diagnostic Tests:
Labs: CBC, CMP, Lipids, TSH, and Iron Panel
A.
Differential Diagnoses
1. Hypertension
High blood pressure is associated with the increased force that blood exerts against the walls of blood vessels. It depends on how hard the heart works and the resistance of the blood vessel walls. It develops and worsens over time, leading to cardiovascular complications such as heart attack, stroke, heart failure, and aneurysm (Mills et al., 2020). A person may not notice symptoms, but the common presentations include sweating, anxiety, sleeping problem, and blushing.
2. Preeclampsia
Preeclampsia is a complication associated with pregnancy. It is often characterized by elevated blood pressure and signs of damaged organs, particularly the liver and kidney. It starts after 20 weeks of pregnancy in women with normal blood pressure (Burton et al., 2019). Clinical presentations include proteinuria, severe headaches, blurred vision, upper abdominal pain, nausea and vomiting, thrombocytopenia, impaired liver function, and shortness of breath.
3. HELP Syndrome
Hemolysis, Elevated Liver Enzymes, and Low Platelet count (HELP) Syndrome are rare but severe illnesses during pregnancy or immediately after delivery. Clinical presentations often come on quickly and may include fatigue, blurred vision, headaches, sudden weight gain, nausea, seizures, and nose bleeding (Wallace et al., 2018). Also, a patient may experience swelling of the face and hands.
P.
For this patient the treatment plan will depend on if her BP remains stable, her treatment plan will be to continue with the current medications and check BP twice daily at home and keep a log. She will bring the logbook to the next clinic appointment in 1 week for review. After reviewing labs and BP logbook, any needed medication changes will be made. Also, the patient is to return to the clinic in 1 week to review lab results and review the BP logbook. This case was informative as I learned to pay attention to the minor information and symptoms as they can help distinguish between closely related conditions. The patient can manage hypertension by lifestyle modification such as eating balanced and healthy nutrition. Also, she needs to know the importance of maintaining BP monitoring and frequent checkups.
References
Burton, G. J., Redman, C. W., Roberts, J. M., & Moffett, A. (2019). Preeclampsia: pathophysiology and clinical implications. BMJ, 366. https://doi.org/10.1136/bmj.l2381
Mills, K. T., Stefanescu, A., & He, J. (2020). The global epidemiology of hypertension. Nature Reviews Nephrology, 16(4), 223-237. https://doi.org/10.1038/s41581-019-0244-2
Wallace, K., Harris, S., Addison, A., & Bean, C. (2018). HELLP syndrome: pathophysiology and current therapies. Current pharmaceutical biotechnology, 19(10), 816-826. https://doi.org/10.2174/1389201019666180712115215
What Students Are Saying About Us
.......... Customer ID: 12*** | Rating: ⭐⭐⭐⭐⭐"Honestly, I was afraid to send my paper to you, but you proved you are a trustworthy service. My essay was done in less than a day, and I received a brilliant piece. I didn’t even believe it was my essay at first 🙂 Great job, thank you!"
.......... Customer ID: 11***| Rating: ⭐⭐⭐⭐⭐
"This company is the best there is. They saved me so many times, I cannot even keep count. Now I recommend it to all my friends, and none of them have complained about it. The writers here are excellent."
"Order a custom Paper on Similar Assignment at essayfount.com! No Plagiarism! Enjoy 20% Discount!"
