soap note week 4

Home>Homework Answsers>Nursing homework helpWORKstudydue in 2 hours9 months ago22.11.202420Report issuefiles (2)week4casestudysoapnotequestions1.docxAdultGeroSOAPNoteTemplate2023821.docxweek4casestudysoapnotequestions1.docxHannahis 38 years old, G1P0, 32 weeks EGA and comes to you for her routine prenatal appointment.  Her BP is 156/96 and her urine has 2+ protein.  She complains of having a headache that will not go away and just not feeling “right” for the past 7 days.Write a brief SOAP note regarding this patient. Make sure to include your answers to these questions in your SOAP note.Subjective:What other relevant questions should you ask regarding the HPI?O- when did you started to experience the headaches? A couple weeks agoL- What side of your head is the pain located? In the front of my head both sidesD- How long does the headache lasts? For a couple hoursC- How does the headache feels? Throbbing, aching, pressure or pulsating? PulsatingA- What makes the headache better or worse? When I lay down in my bed the headaches tend to get worst. Tylenol usually helpsR- Does the headache radiates to your neck or any other part of your head? No, it does not radiateT- At what time during the day do you experience the headaches? Usually in the afternoonS- Scale 0-10 what number will you give the headache? 7· Have you hurt your head recently? No· Are you drinking enough water?· Any changes in your vision? No· Any changes in your mental status? No· Any recent seizure activity? No· Have you change anything in your diet? I have been craving a lot of food containing carbohydratesWhat other medical history questions should you ask?· History of hypertension?· History of heart problems in her family?· Recent hospitalizationWhat other OB history questions should you ask?Objective:Describe the appropriate physical assessment that needs to be included in this visit.BMIVision checks for (scotoma, papilledema, vascular spasms, arteriovenous nicking)Neuro assessment (headaches, CNS involvement, seizures)Abdomen RUQ pain (liver involvement)Musculoskeletal -Deep tendon reflexSkin assessment (bruising)Mouth (bleeding gums)Respiratory (lung sounds for pulmonary edema, SOB)Vascular- presence of worsening edemaExplain what test(s) you will order and perform and discuss your rationale for ordering and performing each test.A CBC will be ordered in this case patient signs and symptoms suggest preeclampsia. Patients with preeclampsia usually have a platelet count of <100,000/microliter putting the patient at high risk of bleeding. Serum creatinine level, in patients with preeclampsia creatinine levels are >1.1mg/dl. Liver chemistry, elevated liver enzymes is usually seen in patients with this condition which can lead to other complications. Quantitative urinary protein. Fetal ultrasound to evaluate amniotic fluid volume and estimate fetal weight due to the high risk of oligohydramnios and fetal growth restrictions in patients with preeclampsia. If patients’ tests are negative for preeclampsia other test will be ordered depending on the patient presenting symptoms and objective data. Also, will like to include a chest x-ray if pulmonary edema is suspected.Assessment/ Diagnosis:What is your diagnosis?Mild to Moderate Preeclampsia(ICD-10: O14.0)Preeclampsia is a multisystem disorder mostly characterized by hypertension and proteinuria. Patients usually develop preeclampsia after 20 weeks of gestation or in the postpartum period. Preeclampsia can also include other organs including liver, the CNS system, ophthalmic, hematological, respiratory and the inflammatory system (August & Sibai, 2024). Patients with preeclampsia usually present with BP >140/90, proteinuria, headache, pulmonary edema, and visual disturbance. In this case patient is 32 weeks EGA with a BP 156/96, constant headache and 2+ proteinuria suggesting evaluation for preeclampsia. After reviewing patient signs and symptoms and using the ACOG preeclampsia criteria, I was able to diagnose patient with preeclampsiaInclude any appropriate differential diagnosis.Gestational hypertension (ICD-10: O13.3)Liver disease (ICD-10: K76.9)Plan:Do you feel that this can be managed via outpatient? Why? How will you manage this?Yes, this patient can be managed in the outpatient setting. Patient is not exhibiting any signs or symptoms that will prompt an emergency referral. Patient can be managed in the clinic, if patient conditions start to deteriorate, abnormal lab results or increased in BP. Patient will be referred to the emergency department. Patients with severe preeclampsia are at risk of liver failure, renal failure, DIC, CNS abnormalities and fetal complications (Jordan et al., 2018).Do you feel that should be managed inpatient? Why? What do you think will be done in patient?No, I don’t feel this should be manage inpatient unless patient starts to present other symptoms or unable to get patient blood pressure under control.If you chose to manage outpatient- explain the medication regimen, testing, and follow up that needs to be done.If I chose to care for this patient as an outpatient, I would start antihypertensive medication with labetalol or nifedipine to regulate her blood pressure and avoid problems. I would emphasize adherence and side effects. I would additionally request weekly CBC, serum creatinine, liver enzymes, and quantitative urine protein to evaluate preeclampsia progression or severity. Biophysical profiles and growth ultrasounds will check fetal well-being every 2-4 weeks, depending on initial results. To monitor and manage her issues, I would arrange biweekly blood pressure tests and prenatal visits. I would teach them to recognize severe preeclampsia symptoms such chronic headache, visual changes, RUQ discomfort, and reduced fetal activity and to seek medical assistance immediately. Her blood pressure and symptoms would be reassessed in 2-3 days, with more frequent visits as required dependent on her health and test findings. I would immediately send her to the hospital for inpatient care and assessment if her illness worsened or she could not handle it outpatiently.If you chose to manage inpatient- explain what medication and testing will be done in patient, and how will you continue management once patient is discharged. What medication and testing do you need to continue for this patient?If I chose to handle this patient inpatient, I would admit her to a high-risk obstetrics unit for preeclampsia monitoring. To prevent seizures, magnesium sulfate would be given, and labetalol or hydralazine would be given to lower her blood pressure to 160/110 mmHg without hypotension. Continuous fetal monitoring would identify signals of distress, while maternal monitoring would include regular vital sign, deep tendon reflex, and urine output checks for increasing symptoms or complications including HELLP syndrome. If HELLP syndrome is suspected, CBC, metabolic panel, quantitative urine protein, and coagulation investigations would be performed (S et al., 2023). Clinical progression may need daily labs. A fetal ultrasound and biophysical profile would assess growth, amniotic fluid levels, and well-being. Once stable and suitable for release, I would switch her to oral antihypertensive treatment like nifedipine with careful outpatient follow-up. Until delivery, blood pressure, CBC, liver function, and urine protein tests, and biophysical profiles and growth ultrasounds would be done weekly. Patient education would emphasize severe preeclampsia symptoms and follow-up treatment compliance (Chang et al., 2023). Since birth is the only therapy for preeclampsia, I would create a controlled delivery plan to reduce maternal and fetal risks.What patient education is important to include for this patient?Patient education is critical for controlling preeclampsia and reducing risks to mother and child. I would start by describing preeclampsia, which involves high blood pressure and organ involvement and may be hazardous if ignored. She must understand the necessity of regular follow-up, blood testing, and fetal monitoring to discover issues early. I would advise her to take antihypertensives as recommended and discuss negative effects like dizziness and exhaustion (Chang et al., 2023). The following symptoms of deteriorating preeclampsia must be reported: severe or persistent headaches, visual changes like blurriness or flashing lights, abrupt swelling (particularly in the face or hands), shortness of breath, RUQ discomfort, or reduced fetal activity. I would recommend regular blood pressure tests at home and maintaining a journal for checkups. Lifestyle advice include keeping hydrated, avoiding sodium, getting enough rest, and avoiding hard exercise. I would also emphasize early birth planning as preeclampsia typically requires preterm delivery (Chang et al., 2023). I would provide comfort and emotional support, understanding that preeclampsia may be daunting but that with careful treatment, positive results are possible. I would also give written materials and clear directions to reinforce comprehension and encourage her to ask questions between sessions.Explain complications that can occur if patient does not comply with treatment regimen.If the patient does not follow her preeclampsia treatment regimen, she risks serious complications that might harm her and her baby. Uncontrolled hypertension may cause maternal stroke, heart failure, liver rupture, renal failure, and HELLP syndrome. Eclampsia, which may harm or kill both the mother and the fetus, is also more likely in non-compliant individuals. Placental abruption, extensive bleeding, fetal discomfort, and early birth, may result from uncontrolled blood pressure and proteinuria. Preeclampsia may cause IUGR, oligohydramnios, and premature delivery, which increase infant morbidity and death (Abdullahi et al., 2024). Untreated preeclampsia may cause multiorgan failure, DIC, and maternal mortality. The likelihood of postpartum problems such bleeding and chronic hypertension rises. Non-adherence to antihypertensive drugs, lifestyle modifications, or follow-up visits may delay diagnosis and make these significant problems harder to treat (Abdullahi et al., 2024). Preventing life-threatening complications and achieving the greatest results for mother and child requires educating the patient about the repercussions of non-compliance and the need of treatment plan adherence.Provide evidence from the research to support your decision-making.Preventing maternal and fetal problems requires close preeclampsia monitoring and therapy, according to evidence-based recommendations. Early detection and therapy of hypertension during pregnancy reduce the risks of stroke, eclampsia, and organ damage, according to the American College of Obstetricians and Gynecologists (ACOG) (Garovic et al., 2021). Labetalol and nifedipine lower blood pressure without affecting uteroplacental blood flow, supporting its usage in outpatient and hospital settings. Research also shows that magnesium sulfate greatly reduces preeclampsia seizures (Sharma et al., 2024). Biophysical profiles and growth ultrasounds may detect fetal discomfort or growth limitation early, improving outcomes.ReferencesAbdullahi, F. M., Tornes, Y. F., Migisha, R., Kalyebara, P. K., Leevan Tibaijuka, Ngonzi, J., Musa Kayondo, Onesmus Byamukama, Turanzomwe, S., Rwebazibwa, J., Ainomugisha, B., Rogers Kajabwangu, Mugyenyi, G. R., & Lugobe, H. M. (2024). HELLP syndrome and associated factors among pregnant women with preeclampsia/eclampsia at a referral hospital in southwestern Uganda: a cross-sectional study.BMC Pregnancy and Childbirth,24(1). https://doi.org/10.1186/s12884-024-06835-yAugust, P., & Sibai, B. (2024, October).Preeclampsia: Clinical features and diagnosis. UpToDate. https://www.uptodate.com/contents/preeclampsia-clinical-features-and-diagnosis?search=preeclampsia%20diagnosis&source=search_result&selectedTitle=1%7E150&usage_type=default&display_rank=1#H1Berens, P. (2024, May 28).Overview of the postpartum period: Disorders and complications. UpToDate.https://www.uptodate.com/contents/overview-of-the-postpartum-period-disorders-and-complications?search=Post%20partum%20hemorrhage%20signs%20and%20symptoms&source=search_result&selectedTitle=1%7E150&usage_type=default&display_rank=1Chang, K.-J., Seow, K.-M., & Chen, K.-H. (2023). Preeclampsia: Recent Advances in Predicting, Preventing, and Managing the Maternal and Fetal Life-Threatening Condition.International Journal of Environmental Research and Public Health,20(4), 2994. https://doi.org/10.3390/ijerph20042994Garovic, V. D., Dechend, R., Easterling, T., Karumanchi, S. A., McMurtry Baird, S., Magee, L. A., Rana, S., Vermunt, J. V., & August, P. (2021). Hypertension in pregnancy: Diagnosis, blood pressure goals, and pharmacotherapy: A Scientific Statement From the American Heart Association.Hypertension,79(2).Jordan, R. G., Farley, C. L., & Grace, K. T. (2018).Prenatal and postnatal care: A Woman-Centered Approach. John Wiley & Sons.Raza, S. K., & Raza, S. (2023, June 26).Postpartum psychosis. StatPearls – NCBI Bookshelf. https://www.ncbi.nlm.nih.gov/books/NBK544304/#:~:text=Once%20organic%20causes%20have%20been,%2C%20quetiapine%2C%20olanzapine%2C%20etc.S, D., Novri, D. A., Hamidy, Y., & Savira, M. (2023). Effectiveness of nifedipine, labetalol, and hydralazine as emergency antihypertension in severe preeclampsia: a randomized control trial.F1000Research,11, 1287. https://doi.org/10.12688/f1000research.125944.2Sharma, D. D., Chandresh, N. R., Javed, A., Girgis, P., Zeeshan, M., Fatima, S. S., Arab, T. T., Gopidasan, S., Daddala, V. C., Vaghasiya, K. V., Soofia, A., Mylavarapu, M., Sharma, D. D., Chandresh, N. R., Javed, A., Girgis, P., Zeeshan, M., Fatima, S. S., Arab, T. T., & Gopidasan, S. (2024). The Management of Preeclampsia: A Comprehensive Review of Current Practices and Future Directions.Cureus,16(1). https://doi.org/10.7759/cureus.51512AdultGeroSOAPNoteTemplate2023821.docxThis file is too large to display.View in new windowAdultGeroSOAPNoteTemplate2023821.docxThis file is too large to display.View in new windowweek4casestudysoapnotequestions1.docxHannahis 38 years old, G1P0, 32 weeks EGA and comes to you for her routine prenatal appointment.  Her BP is 156/96 and her urine has 2+ protein.  She complains of having a headache that will not go away and just not feeling “right” for the past 7 days.Write a brief SOAP note regarding this patient. Make sure to include your answers to these questions in your SOAP note.Subjective:What other relevant questions should you ask regarding the HPI?O- when did you started to experience the headaches? A couple weeks agoL- What side of your head is the pain located? In the front of my head both sidesD- How long does the headache lasts? For a couple hoursC- How does the headache feels? Throbbing, aching, pressure or pulsating? PulsatingA- What makes the headache better or worse? When I lay down in my bed the headaches tend to get worst. Tylenol usually helpsR- Does the headache radiates to your neck or any other part of your head? No, it does not radiateT- At what time during the day do you experience the headaches? Usually in the afternoonS- Scale 0-10 what number will you give the headache? 7· Have you hurt your head recently? No· Are you drinking enough water?· Any changes in your vision? No· Any changes in your mental status? No· Any recent seizure activity? No· Have you change anything in your diet? I have been craving a lot of food containing carbohydratesWhat other medical history questions should you ask?· History of hypertension?· History of heart problems in her family?· Recent hospitalizationWhat other OB history questions should you ask?Objective:Describe the appropriate physical assessment that needs to be included in this visit.BMIVision checks for (scotoma, papilledema, vascular spasms, arteriovenous nicking)Neuro assessment (headaches, CNS involvement, seizures)Abdomen RUQ pain (liver involvement)Musculoskeletal -Deep tendon reflexSkin assessment (bruising)Mouth (bleeding gums)Respiratory (lung sounds for pulmonary edema, SOB)Vascular- presence of worsening edemaExplain what test(s) you will order and perform and discuss your rationale for ordering and performing each test.A CBC will be ordered in this case patient signs and symptoms suggest preeclampsia. Patients with preeclampsia usually have a platelet count of <100,000/microliter putting the patient at high risk of bleeding. Serum creatinine level, in patients with preeclampsia creatinine levels are >1.1mg/dl. Liver chemistry, elevated liver enzymes is usually seen in patients with this condition which can lead to other complications. Quantitative urinary protein. Fetal ultrasound to evaluate amniotic fluid volume and estimate fetal weight due to the high risk of oligohydramnios and fetal growth restrictions in patients with preeclampsia. If patients’ tests are negative for preeclampsia other test will be ordered depending on the patient presenting symptoms and objective data. Also, will like to include a chest x-ray if pulmonary edema is suspected.Assessment/ Diagnosis:What is your diagnosis?Mild to Moderate Preeclampsia(ICD-10: O14.0)Preeclampsia is a multisystem disorder mostly characterized by hypertension and proteinuria. Patients usually develop preeclampsia after 20 weeks of gestation or in the postpartum period. Preeclampsia can also include other organs including liver, the CNS system, ophthalmic, hematological, respiratory and the inflammatory system (August & Sibai, 2024). Patients with preeclampsia usually present with BP >140/90, proteinuria, headache, pulmonary edema, and visual disturbance. In this case patient is 32 weeks EGA with a BP 156/96, constant headache and 2+ proteinuria suggesting evaluation for preeclampsia. After reviewing patient signs and symptoms and using the ACOG preeclampsia criteria, I was able to diagnose patient with preeclampsiaInclude any appropriate differential diagnosis.Gestational hypertension (ICD-10: O13.3)Liver disease (ICD-10: K76.9)Plan:Do you feel that this can be managed via outpatient? Why? How will you manage this?Yes, this patient can be managed in the outpatient setting. Patient is not exhibiting any signs or symptoms that will prompt an emergency referral. Patient can be managed in the clinic, if patient conditions start to deteriorate, abnormal lab results or increased in BP. Patient will be referred to the emergency department. Patients with severe preeclampsia are at risk of liver failure, renal failure, DIC, CNS abnormalities and fetal complications (Jordan et al., 2018).Do you feel that should be managed inpatient? Why? What do you think will be done in patient?No, I don’t feel this should be manage inpatient unless patient starts to present other symptoms or unable to get patient blood pressure under control.If you chose to manage outpatient- explain the medication regimen, testing, and follow up that needs to be done.If I chose to care for this patient as an outpatient, I would start antihypertensive medication with labetalol or nifedipine to regulate her blood pressure and avoid problems. I would emphasize adherence and side effects. I would additionally request weekly CBC, serum creatinine, liver enzymes, and quantitative urine protein to evaluate preeclampsia progression or severity. Biophysical profiles and growth ultrasounds will check fetal well-being every 2-4 weeks, depending on initial results. To monitor and manage her issues, I would arrange biweekly blood pressure tests and prenatal visits. I would teach them to recognize severe preeclampsia symptoms such chronic headache, visual changes, RUQ discomfort, and reduced fetal activity and to seek medical assistance immediately. Her blood pressure and symptoms would be reassessed in 2-3 days, with more frequent visits as required dependent on her health and test findings. I would immediately send her to the hospital for inpatient care and assessment if her illness worsened or she could not handle it outpatiently.If you chose to manage inpatient- explain what medication and testing will be done in patient, and how will you continue management once patient is discharged. What medication and testing do you need to continue for this patient?If I chose to handle this patient inpatient, I would admit her to a high-risk obstetrics unit for preeclampsia monitoring. To prevent seizures, magnesium sulfate would be given, and labetalol or hydralazine would be given to lower her blood pressure to 160/110 mmHg without hypotension. Continuous fetal monitoring would identify signals of distress, while maternal monitoring would include regular vital sign, deep tendon reflex, and urine output checks for increasing symptoms or complications including HELLP syndrome. If HELLP syndrome is suspected, CBC, metabolic panel, quantitative urine protein, and coagulation investigations would be performed (S et al., 2023). Clinical progression may need daily labs. A fetal ultrasound and biophysical profile would assess growth, amniotic fluid levels, and well-being. Once stable and suitable for release, I would switch her to oral antihypertensive treatment like nifedipine with careful outpatient follow-up. Until delivery, blood pressure, CBC, liver function, and urine protein tests, and biophysical profiles and growth ultrasounds would be done weekly. Patient education would emphasize severe preeclampsia symptoms and follow-up treatment compliance (Chang et al., 2023). Since birth is the only therapy for preeclampsia, I would create a controlled delivery plan to reduce maternal and fetal risks.What patient education is important to include for this patient?Patient education is critical for controlling preeclampsia and reducing risks to mother and child. I would start by describing preeclampsia, which involves high blood pressure and organ involvement and may be hazardous if ignored. She must understand the necessity of regular follow-up, blood testing, and fetal monitoring to discover issues early. I would advise her to take antihypertensives as recommended and discuss negative effects like dizziness and exhaustion (Chang et al., 2023). The following symptoms of deteriorating preeclampsia must be reported: severe or persistent headaches, visual changes like blurriness or flashing lights, abrupt swelling (particularly in the face or hands), shortness of breath, RUQ discomfort, or reduced fetal activity. I would recommend regular blood pressure tests at home and maintaining a journal for checkups. Lifestyle advice include keeping hydrated, avoiding sodium, getting enough rest, and avoiding hard exercise. I would also emphasize early birth planning as preeclampsia typically requires preterm delivery (Chang et al., 2023). I would provide comfort and emotional support, understanding that preeclampsia may be daunting but that with careful treatment, positive results are possible. I would also give written materials and clear directions to reinforce comprehension and encourage her to ask questions between sessions.Explain complications that can occur if patient does not comply with treatment regimen.If the patient does not follow her preeclampsia treatment regimen, she risks serious complications that might harm her and her baby. Uncontrolled hypertension may cause maternal stroke, heart failure, liver rupture, renal failure, and HELLP syndrome. Eclampsia, which may harm or kill both the mother and the fetus, is also more likely in non-compliant individuals. Placental abruption, extensive bleeding, fetal discomfort, and early birth, may result from uncontrolled blood pressure and proteinuria. Preeclampsia may cause IUGR, oligohydramnios, and premature delivery, which increase infant morbidity and death (Abdullahi et al., 2024). Untreated preeclampsia may cause multiorgan failure, DIC, and maternal mortality. The likelihood of postpartum problems such bleeding and chronic hypertension rises. Non-adherence to antihypertensive drugs, lifestyle modifications, or follow-up visits may delay diagnosis and make these significant problems harder to treat (Abdullahi et al., 2024). Preventing life-threatening complications and achieving the greatest results for mother and child requires educating the patient about the repercussions of non-compliance and the need of treatment plan adherence.Provide evidence from the research to support your decision-making.Preventing maternal and fetal problems requires close preeclampsia monitoring and therapy, according to evidence-based recommendations. Early detection and therapy of hypertension during pregnancy reduce the risks of stroke, eclampsia, and organ damage, according to the American College of Obstetricians and Gynecologists (ACOG) (Garovic et al., 2021). Labetalol and nifedipine lower blood pressure without affecting uteroplacental blood flow, supporting its usage in outpatient and hospital settings. Research also shows that magnesium sulfate greatly reduces preeclampsia seizures (Sharma et al., 2024). Biophysical profiles and growth ultrasounds may detect fetal discomfort or growth limitation early, improving outcomes.ReferencesAbdullahi, F. M., Tornes, Y. F., Migisha, R., Kalyebara, P. K., Leevan Tibaijuka, Ngonzi, J., Musa Kayondo, Onesmus Byamukama, Turanzomwe, S., Rwebazibwa, J., Ainomugisha, B., Rogers Kajabwangu, Mugyenyi, G. R., & Lugobe, H. M. (2024). HELLP syndrome and associated factors among pregnant women with preeclampsia/eclampsia at a referral hospital in southwestern Uganda: a cross-sectional study.BMC Pregnancy and Childbirth,24(1). https://doi.org/10.1186/s12884-024-06835-yAugust, P., & Sibai, B. (2024, October).Preeclampsia: Clinical features and diagnosis. UpToDate. https://www.uptodate.com/contents/preeclampsia-clinical-features-and-diagnosis?search=preeclampsia%20diagnosis&source=search_result&selectedTitle=1%7E150&usage_type=default&display_rank=1#H1Berens, P. (2024, May 28).Overview of the postpartum period: Disorders and complications. UpToDate.https://www.uptodate.com/contents/overview-of-the-postpartum-period-disorders-and-complications?search=Post%20partum%20hemorrhage%20signs%20and%20symptoms&source=search_result&selectedTitle=1%7E150&usage_type=default&display_rank=1Chang, K.-J., Seow, K.-M., & Chen, K.-H. (2023). Preeclampsia: Recent Advances in Predicting, Preventing, and Managing the Maternal and Fetal Life-Threatening Condition.International Journal of Environmental Research and Public Health,20(4), 2994. https://doi.org/10.3390/ijerph20042994Garovic, V. D., Dechend, R., Easterling, T., Karumanchi, S. A., McMurtry Baird, S., Magee, L. A., Rana, S., Vermunt, J. V., & August, P. (2021). Hypertension in pregnancy: Diagnosis, blood pressure goals, and pharmacotherapy: A Scientific Statement From the American Heart Association.Hypertension,79(2).Jordan, R. G., Farley, C. L., & Grace, K. T. (2018).Prenatal and postnatal care: A Woman-Centered Approach. John Wiley & Sons.Raza, S. K., & Raza, S. (2023, June 26).Postpartum psychosis. StatPearls – NCBI Bookshelf. https://www.ncbi.nlm.nih.gov/books/NBK544304/#:~:text=Once%20organic%20causes%20have%20been,%2C%20quetiapine%2C%20olanzapine%2C%20etc.S, D., Novri, D. A., Hamidy, Y., & Savira, M. (2023). Effectiveness of nifedipine, labetalol, and hydralazine as emergency antihypertension in severe preeclampsia: a randomized control trial.F1000Research,11, 1287. https://doi.org/10.12688/f1000research.125944.2Sharma, D. D., Chandresh, N. R., Javed, A., Girgis, P., Zeeshan, M., Fatima, S. S., Arab, T. T., Gopidasan, S., Daddala, V. C., Vaghasiya, K. V., Soofia, A., Mylavarapu, M., Sharma, D. D., Chandresh, N. R., Javed, A., Girgis, P., Zeeshan, M., Fatima, S. S., Arab, T. T., & Gopidasan, S. (2024). The Management of Preeclampsia: A Comprehensive Review of Current Practices and Future Directions.Cureus,16(1). https://doi.org/10.7759/cureus.51512AdultGeroSOAPNoteTemplate2023821.docxThis file is too large to display.View in new windowweek4casestudysoapnotequestions1.docxHannahis 38 years old, G1P0, 32 weeks EGA and comes to you for her routine prenatal appointment.  Her BP is 156/96 and her urine has 2+ protein.  She complains of having a headache that will not go away and just not feeling “right” for the past 7 days.Write a brief SOAP note regarding this patient. Make sure to include your answers to these questions in your SOAP note.Subjective:What other relevant questions should you ask regarding the HPI?O- when did you started to experience the headaches? A couple weeks agoL- What side of your head is the pain located? In the front of my head both sidesD- How long does the headache lasts? For a couple hoursC- How does the headache feels? Throbbing, aching, pressure or pulsating? PulsatingA- What makes the headache better or worse? When I lay down in my bed the headaches tend to get worst. Tylenol usually helpsR- Does the headache radiates to your neck or any other part of your head? No, it does not radiateT- At what time during the day do you experience the headaches? Usually in the afternoonS- Scale 0-10 what number will you give the headache? 7· Have you hurt your head recently? No· Are you drinking enough water?· Any changes in your vision? No· Any changes in your mental status? No· Any recent seizure activity? No· Have you change anything in your diet? I have been craving a lot of food containing carbohydratesWhat other medical history questions should you ask?· History of hypertension?· History of heart problems in her family?· Recent hospitalizationWhat other OB history questions should you ask?Objective:Describe the appropriate physical assessment that needs to be included in this visit.BMIVision checks for (scotoma, papilledema, vascular spasms, arteriovenous nicking)Neuro assessment (headaches, CNS involvement, seizures)Abdomen RUQ pain (liver involvement)Musculoskeletal -Deep tendon reflexSkin assessment (bruising)Mouth (bleeding gums)Respiratory (lung sounds for pulmonary edema, SOB)Vascular- presence of worsening edemaExplain what test(s) you will order and perform and discuss your rationale for ordering and performing each test.A CBC will be ordered in this case patient signs and symptoms suggest preeclampsia. Patients with preeclampsia usually have a platelet count of <100,000/microliter putting the patient at high risk of bleeding. Serum creatinine level, in patients with preeclampsia creatinine levels are >1.1mg/dl. Liver chemistry, elevated liver enzymes is usually seen in patients with this condition which can lead to other complications. Quantitative urinary protein. Fetal ultrasound to evaluate amniotic fluid volume and estimate fetal weight due to the high risk of oligohydramnios and fetal growth restrictions in patients with preeclampsia. If patients’ tests are negative for preeclampsia other test will be ordered depending on the patient presenting symptoms and objective data. Also, will like to include a chest x-ray if pulmonary edema is suspected.Assessment/ Diagnosis:What is your diagnosis?Mild to Moderate Preeclampsia(ICD-10: O14.0)Preeclampsia is a multisystem disorder mostly characterized by hypertension and proteinuria. Patients usually develop preeclampsia after 20 weeks of gestation or in the postpartum period. Preeclampsia can also include other organs including liver, the CNS system, ophthalmic, hematological, respiratory and the inflammatory system (August & Sibai, 2024). Patients with preeclampsia usually present with BP >140/90, proteinuria, headache, pulmonary edema, and visual disturbance. In this case patient is 32 weeks EGA with a BP 156/96, constant headache and 2+ proteinuria suggesting evaluation for preeclampsia. After reviewing patient signs and symptoms and using the ACOG preeclampsia criteria, I was able to diagnose patient with preeclampsiaInclude any appropriate differential diagnosis.Gestational hypertension (ICD-10: O13.3)Liver disease (ICD-10: K76.9)Plan:Do you feel that this can be managed via outpatient? Why? How will you manage this?Yes, this patient can be managed in the outpatient setting. Patient is not exhibiting any signs or symptoms that will prompt an emergency referral. Patient can be managed in the clinic, if patient conditions start to deteriorate, abnormal lab results or increased in BP. Patient will be referred to the emergency department. Patients with severe preeclampsia are at risk of liver failure, renal failure, DIC, CNS abnormalities and fetal complications (Jordan et al., 2018).Do you feel that should be managed inpatient? Why? What do you think will be done in patient?No, I don’t feel this should be manage inpatient unless patient starts to present other symptoms or unable to get patient blood pressure under control.If you chose to manage outpatient- explain the medication regimen, testing, and follow up that needs to be done.If I chose to care for this patient as an outpatient, I would start antihypertensive medication with labetalol or nifedipine to regulate her blood pressure and avoid problems. I would emphasize adherence and side effects. I would additionally request weekly CBC, serum creatinine, liver enzymes, and quantitative urine protein to evaluate preeclampsia progression or severity. Biophysical profiles and growth ultrasounds will check fetal well-being every 2-4 weeks, depending on initial results. To monitor and manage her issues, I would arrange biweekly blood pressure tests and prenatal visits. I would teach them to recognize severe preeclampsia symptoms such chronic headache, visual changes, RUQ discomfort, and reduced fetal activity and to seek medical assistance immediately. Her blood pressure and symptoms would be reassessed in 2-3 days, with more frequent visits as required dependent on her health and test findings. I would immediately send her to the hospital for inpatient care and assessment if her illness worsened or she could not handle it outpatiently.If you chose to manage inpatient- explain what medication and testing will be done in patient, and how will you continue management once patient is discharged. What medication and testing do you need to continue for this patient?If I chose to handle this patient inpatient, I would admit her to a high-risk obstetrics unit for preeclampsia monitoring. To prevent seizures, magnesium sulfate would be given, and labetalol or hydralazine would be given to lower her blood pressure to 160/110 mmHg without hypotension. Continuous fetal monitoring would identify signals of distress, while maternal monitoring would include regular vital sign, deep tendon reflex, and urine output checks for increasing symptoms or complications including HELLP syndrome. If HELLP syndrome is suspected, CBC, metabolic panel, quantitative urine protein, and coagulation investigations would be performed (S et al., 2023). Clinical progression may need daily labs. A fetal ultrasound and biophysical profile would assess growth, amniotic fluid levels, and well-being. Once stable and suitable for release, I would switch her to oral antihypertensive treatment like nifedipine with careful outpatient follow-up. Until delivery, blood pressure, CBC, liver function, and urine protein tests, and biophysical profiles and growth ultrasounds would be done weekly. Patient education would emphasize severe preeclampsia symptoms and follow-up treatment compliance (Chang et al., 2023). Since birth is the only therapy for preeclampsia, I would create a controlled delivery plan to reduce maternal and fetal risks.What patient education is important to include for this patient?Patient education is critical for controlling preeclampsia and reducing risks to mother and child. I would start by describing preeclampsia, which involves high blood pressure and organ involvement and may be hazardous if ignored. She must understand the necessity of regular follow-up, blood testing, and fetal monitoring to discover issues early. I would advise her to take antihypertensives as recommended and discuss negative effects like dizziness and exhaustion (Chang et al., 2023). The following symptoms of deteriorating preeclampsia must be reported: severe or persistent headaches, visual changes like blurriness or flashing lights, abrupt swelling (particularly in the face or hands), shortness of breath, RUQ discomfort, or reduced fetal activity. I would recommend regular blood pressure tests at home and maintaining a journal for checkups. Lifestyle advice include keeping hydrated, avoiding sodium, getting enough rest, and avoiding hard exercise. I would also emphasize early birth planning as preeclampsia typically requires preterm delivery (Chang et al., 2023). I would provide comfort and emotional support, understanding that preeclampsia may be daunting but that with careful treatment, positive results are possible. I would also give written materials and clear directions to reinforce comprehension and encourage her to ask questions between sessions.Explain complications that can occur if patient does not comply with treatment regimen.If the patient does not follow her preeclampsia treatment regimen, she risks serious complications that might harm her and her baby. Uncontrolled hypertension may cause maternal stroke, heart failure, liver rupture, renal failure, and HELLP syndrome. Eclampsia, which may harm or kill both the mother and the fetus, is also more likely in non-compliant individuals. Placental abruption, extensive bleeding, fetal discomfort, and early birth, may result from uncontrolled blood pressure and proteinuria. Preeclampsia may cause IUGR, oligohydramnios, and premature delivery, which increase infant morbidity and death (Abdullahi et al., 2024). Untreated preeclampsia may cause multiorgan failure, DIC, and maternal mortality. The likelihood of postpartum problems such bleeding and chronic hypertension rises. Non-adherence to antihypertensive drugs, lifestyle modifications, or follow-up visits may delay diagnosis and make these significant problems harder to treat (Abdullahi et al., 2024). Preventing life-threatening complications and achieving the greatest results for mother and child requires educating the patient about the repercussions of non-compliance and the need of treatment plan adherence.Provide evidence from the research to support your decision-making.Preventing maternal and fetal problems requires close preeclampsia monitoring and therapy, according to evidence-based recommendations. Early detection and therapy of hypertension during pregnancy reduce the risks of stroke, eclampsia, and organ damage, according to the American College of Obstetricians and Gynecologists (ACOG) (Garovic et al., 2021). Labetalol and nifedipine lower blood pressure without affecting uteroplacental blood flow, supporting its usage in outpatient and hospital settings. Research also shows that magnesium sulfate greatly reduces preeclampsia seizures (Sharma et al., 2024). Biophysical profiles and growth ultrasounds may detect fetal discomfort or growth limitation early, improving outcomes.ReferencesAbdullahi, F. M., Tornes, Y. F., Migisha, R., Kalyebara, P. K., Leevan Tibaijuka, Ngonzi, J., Musa Kayondo, Onesmus Byamukama, Turanzomwe, S., Rwebazibwa, J., Ainomugisha, B., Rogers Kajabwangu, Mugyenyi, G. R., & Lugobe, H. M. (2024). HELLP syndrome and associated factors among pregnant women with preeclampsia/eclampsia at a referral hospital in southwestern Uganda: a cross-sectional study.BMC Pregnancy and Childbirth,24(1). https://doi.org/10.1186/s12884-024-06835-yAugust, P., & Sibai, B. (2024, October).Preeclampsia: Clinical features and diagnosis. UpToDate. https://www.uptodate.com/contents/preeclampsia-clinical-features-and-diagnosis?search=preeclampsia%20diagnosis&source=search_result&selectedTitle=1%7E150&usage_type=default&display_rank=1#H1Berens, P. (2024, May 28).Overview of the postpartum period: Disorders and complications. UpToDate.https://www.uptodate.com/contents/overview-of-the-postpartum-period-disorders-and-complications?search=Post%20partum%20hemorrhage%20signs%20and%20symptoms&source=search_result&selectedTitle=1%7E150&usage_type=default&display_rank=1Chang, K.-J., Seow, K.-M., & Chen, K.-H. (2023). Preeclampsia: Recent Advances in Predicting, Preventing, and Managing the Maternal and Fetal Life-Threatening Condition.International Journal of Environmental Research and Public Health,20(4), 2994. https://doi.org/10.3390/ijerph20042994Garovic, V. D., Dechend, R., Easterling, T., Karumanchi, S. A., McMurtry Baird, S., Magee, L. A., Rana, S., Vermunt, J. V., & August, P. (2021). Hypertension in pregnancy: Diagnosis, blood pressure goals, and pharmacotherapy: A Scientific Statement From the American Heart Association.Hypertension,79(2).Jordan, R. G., Farley, C. L., & Grace, K. T. (2018).Prenatal and postnatal care: A Woman-Centered Approach. John Wiley & Sons.Raza, S. K., & Raza, S. (2023, June 26).Postpartum psychosis. StatPearls – NCBI Bookshelf. https://www.ncbi.nlm.nih.gov/books/NBK544304/#:~:text=Once%20organic%20causes%20have%20been,%2C%20quetiapine%2C%20olanzapine%2C%20etc.S, D., Novri, D. A., Hamidy, Y., & Savira, M. (2023). Effectiveness of nifedipine, labetalol, and hydralazine as emergency antihypertension in severe preeclampsia: a randomized control trial.F1000Research,11, 1287. https://doi.org/10.12688/f1000research.125944.2Sharma, D. D., Chandresh, N. R., Javed, A., Girgis, P., Zeeshan, M., Fatima, S. S., Arab, T. T., Gopidasan, S., Daddala, V. C., Vaghasiya, K. V., Soofia, A., Mylavarapu, M., Sharma, D. D., Chandresh, N. R., Javed, A., Girgis, P., Zeeshan, M., Fatima, S. S., Arab, T. T., & Gopidasan, S. (2024). The Management of Preeclampsia: A Comprehensive Review of Current Practices and Future Directions.Cureus,16(1). https://doi.org/10.7759/cureus.51512AdultGeroSOAPNoteTemplate2023821.docxThis file is too large to display.View in new window12Bids(62)Miss DeannaDr. Ellen RMEmily ClareMathProgrammingDr. Aylin JMDr. Sarah Blakeabdul_rehman_Prof Double RSTELLAR GEEK A+Young NyanyaProWritingGuruProf. TOPGRADEgrA+de plusUbaid TariqDr. Adeline Zoefirstclass tutorDr M. 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