CASE SCENARIO#1 PRE-ECLAMPSIA HPI: Patient JB 40 year old G1P0 at… CASE SCENARIO#1 PRE-EC
CASE SCENARIO#1 PRE-ECLAMPSIA HPI: Patient JB 40 year old G1P0 at… CASE SCENARIO#1 PRE-ECLAMPSIA HPI: Patient JB 40 year old G1P0 at 36 weeks gestation seen and examined in the Emergency Room with a chief complaint of severe headache, facial swelling, edema of both upper and lower extremities. Initial vital signs as follows: Temperature- 36.4 degrees Celsius Heart Rate- 85 beats per minute Respiratory rate- 17 BP- 200/110. Routine urinalysis reveals ++ Protein. Leopold’s maneuver done reveals fundic height of 38cm, longitudinal lie, fetal back felt at the right side, on cephalic presentation, head engaged ?. Patient was also attached to an electronic fetal monitor. FHT: 135 bpm, reassuring variability. No deceleration and acceleration noted. Patient felt no contractions at the time of examination. In the ER, JB was given Hydralizine 50 mg SIVP STAT then OD and Magnesium Sulfate 4g IV then 10g IM STAT then 5gm IM q4 hours in alternating buttocks. Patient was advised to be admitted for further observation and management. FAMILY HISTORY: Father- hypertensive, diagnosed with liver cirrhosis Mother- diagnosed with DM type 2 and bronchial asthma PHI: + Seasonal allergies to dust and pollen, long standing asthma- uses Salbutamol inhaler to relieve symptoms. Patient cannot recall when the last attack occurred. OB HISTORY: LMP June 5, 2021 Menarche- 14 years old claims to have a regular cycle, period lasting up to 5 days consuming 4-5 pads fully soaked on Day 2 and 3 with associated dysmenorrhea on those days. PERSONAL HISTORY: married for 10 years, works as medical secretary, smoker and occasional alcoholic beverage drinker but claims she stopped after finding out she’s pregnant. FDAR CHARTING Time & Date Focus Data Action Response Health Science Science Nursing BSN 122 Share QuestionEmailCopy link Comments (0)
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