Daniel DeMarco               Focused H&P #1                  OB/GYN

Chief Complaint: Upper Back Pain, Incidentally found to have high BP

 

History of Present Illness:

TP is a 43yo G7P3033 at 22w2d by LMP with PMH significant for Asthma complaining of upper back pain x 1 week. It has been constant but was getting worse. This morning, she was at Jury Duty when the pain became intolerable. She called the ambulance and was found to have BP of 150 systolic. When brought to ED here, she was immediately sent to OB/GYN triage. Endorses headache, blurry vision, swelling of face, and edema of arms, legs, feet. Denies seizures, loss of consciousness, paresthesias, nausea, vomiting, chest pain, shortness of breath, history of hypertension, previous complications of pregnancy.

Patient was receiving routine prenatal care at a different clinic/facility. Her 3 NSVD were at Nassau Medical Center in Long Island.

 

Obstetric History: Full Term NSVD x 3 (Children are ages 15, 17, and 18yo), Termination of Pregnancy x 3 (D&C)

Gynecologic History: None

PMH: Asthma

Medications: Prenatal Vitamins, Albuterol 108 mcg/ACT inhaler 2 puffs q6h as needed

PSH: D&C x 3 (2008, 1996, 1994)

Allergies: Shrimp, Cholestatin

Family History: Unknown

Social History: Never smoker. No EtOH use. No illicit drug use. Admits sexual activity with male partners.

 

Review of Systems:

General : Admits weight gain. Denies fever, chills, night sweats, loss of appetite, weight loss, weakness, fatigue

Skin, Hair, Nails : Denies change in texture, excessive dryness or sweating, discolorations,

pigmentations, moles, rashes, pruritus, change in hair distribution

Head : Admits headache, facial swelling. Denies trauma, unconsciousness, coma, fracture, vertigo

Eyes : Admits blurry vision. Denies corrective lenses, visual disturbances, fatigue, photophobia, pruritus, lacrimation

Ears : Denies deafness, pain, discharge, tinnitus, hearing aids

Nose/Sinuses : Denies discharge, epistaxis, rhinorrhea, congestion

Mouth/Throat : Denies bleeding gums, sore tongue, sore throat, mouth ulcers, voice changes,

dentures

Neck : Denies lumps, swelling, stiffness, decreased range of motion

Breast : Denies lumps, nipple discharge, pain

Respiratory : Denies dyspnea, shortness of breath, wheezing, cough, hemoptysis, cyanosis, orthopnea, paroxysmal nocturnal dyspnea

Cardiovascular : Denies palpitations, irregular heartbeat, edema, syncope, chest pain, known heart murmur

Gastrointestinal : Denies abdominal pain, change in appetite, intolerance to specific foods, nausea, vomiting, dysphagia, pyrosis, flatulence, eructations, diarrhea, constipation, hemorrhoids, change in stool caliber, blood in stool

Genitourinary : Denies change in frequency, urgency, hesitancy, dribbling, nocturia, polyuria,

oliguria, dysuria, change in urine color, incontinence, flank pain

Musculoskeletal : Admits upper back pain. Denies joint pain, deformity, swelling, redness, arthritis

Peripheral Vascular : Admits peripheral edema. Denies intermittent claudication, coldness or trophic changes, varicose veins, color change

Hematologic : Denies anemia, easy bruising/bleeding, lymph node enlargement, history of

DVT/PE

Endocrine : Denies polyuria, polydipsia, polyphagia, heat or cold intolerance, goiter, hirsutism

Neurologic : Denies seizures, loss of consciousness, sensory disturbances, paresthesia,

dysesthesia, hyperesthesia, ataxia, loss of strength, change in mental status, memory loss,

asymmetric weakness

Psychiatric : Denies feelings of helplessness, feelings of hopelessness, lack of interest in usual

activities, suicidal ideation, anxiety

 

Physical Exam:

Vital Signs:

BP: 219/106

Pulse: 92bpm

RR: 18 breaths/min

Temp: 37.1C

SpO2: 99%RA

Ht: 68 inches

Wt: 107kg

 

General Survey: Patient lying comfortably in bed. No apparent distress.

Skin: No petechiae, masses, lesions. Dorsum of left hand with color tattoo.

Hair: Average quantity and distribution.

Nails: Capillary refill <2s throughout.

HEENT: Head: NC/AT. Non-tender to palpation throughout. No edema. Eyes: PERRLA. EOMs intact.

Cardiovascular: Regular rate and rhythm. S1 and S2. No murmurs, gallops, rubs.

Chest and Pulmonary: Symmetrical rise and fall of chest wall. No labored breathing, accessory muscle use. Clear to auscultation bilaterally. Right upper back minimally tender to palpation.

Abdomen: Fundal Height slightly above the level of the umbilicus. Soft, non-tender. No guarding, rebound tenderness.

Vaginal Exam: Cervix closed.

Extremities and Peripheral Vascular: Upper and Lower extremities symmetrical. Minimal edema of bilateral upper extremities. Bilateral Lower extremities with 2+ pitting edema. Peripheral pulses 2+.

 

Assessment/Plan:

TP is a 43yo G7P3033 at 22w2d by LMP with PMH significant for Asthma admitted with severe preeclampsia.

 

OB/GYN

#Severe Preeclampsia at 22w2d by LMP

• Labetalol 20mg IVP for BP
• Cont. to monitor BP. May consider additional Labetalol or Hydralazine/Nifedipine if BP still elevated
• Magnesium sulfate 4g IVP loading then 2g/h IV to prevent eclampsia/seizures
• Monitor for signs of magnesium toxicity including DTRs, level of consciousness, q15min for first hour, q30min for second hour, and then hourly
• NS at 50cc/hr
• Strict I&Os
• STAT CBC, CMP with Direct, Indirect, and Total Bilirubin, LDH, Uric Acid, T&S, RPR, Rubella Ab, Hep B, HIV, VZV titer, Quad Screen (AFP, estradiol, B-hCG, inhibin alpha subunit). Monitor for HELLP Syndrome
• STAT UA with UCx
• STAT Ultrasound with estimated gestational age and fetal weight and to assess for IUGR
• Given dating by LMP, pregnancy is currently previable. Pending U/S results, may need to discuss management options which may include betamethasone administration for fetal lung maturity and subsequent expectant management or possible delivery versus termination of pregnancy to reduce the risk of maternal complications like cerebrovascular hemorrhage or death or fetal complications like death or severe permanent disability. Consider neonatology consult to determine neonatal prognosis
• Contact Nassau Medical Center and OB/GYN Clinic/Facility for Patient Records

 

Respiratory

#Asthma – Stable

• Cont. Albuterol 108 mcg/ACT inhaler 2 puffs q6h as needed
• Asthma education performed including signs of exacerbations, when to use inhaler, avoidance of common asthma triggers, and when to go to the emergency department

 

Musculoskeletal

#Upper Back Pain – Musculoskeletal Origin versus Radiculopathy

• Given reproducibility on palpation, likely musculoskeletal
• Acetaminophen 325mg PO q4-6h prn; maximum 1g/4h and 4g/24h
• Alternate between ice/heating pad
• Activity as tolerated

 

DVT Prophylaxis with Intermittent Pneumatic Compression

 

/s/ Daniel DeMarco, PA-S

Physician Assistant Student