I human soap note tina sandler

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Subjective CC: “I take my blood pressure at my local pharmacy and when I went it was high” HPI: 29 y.o AA female G5P2111presents at 31 5/7 weeks’ gestation (third trimester) having missed vis... its after being seen at 24 weeks gestation presenting with high blood pressure. At the drug store her systolic blood pressure was 140’s. Pt unaware how long BP has been elevated given she does not check her blood pressure regularly at home, in office BP 146/90. Patient also expressed a 4-pound weight gain this week. 2) Patient also complained of acid reflux while laying supine. 3) patient complains of headaches are a 3/10 pain non-pulsitile. Headaches increase when tension is high between patient and husband and last a few hours a few times a week. Patient has been taking Tylenol to relive headaches. ROS: Cons: elevated blood pressure, acid reflux, HEENT: Patient denies, dizziness, syncope, difficulty hearing, difficulty tasting, blurred vision, ringing of the ears Patient companies of headache CV: Patient denies: chest pain, SOB, chest pressure Patient companies of: increased edema of extremities and face Lungs: Patient denies: SOB, cough, phlem, difficulty breathing Breast: patient denies: Dipple discharge, masses, lesions, ulcerations, or skin variation patient complains of tenderness GI: patient denies: dysuria, incontinence, urgency frequency, painful intercourse GU: Patient denies: nausea, vomiting, weight loss Patient complains of: acid reflux when laying supine, weight gain r/t pregnancy Psych: patient denies depression, anxiety, suicidal ideation complains of: previous domestic violence w/o trauma PMH: ectopic pregnancy, preeclampsia, 3rd trimester pregnancy loss Allergies: Shell-fish Medications: prenatal vitamins SH: patient verbalized no smoking, ETOH use, or recreational drug use during pregnancy Objective VS: 5’5, 190lds, BP 146/90, pulse 82, RR18, temp 97.4, sp02 94% Cons: 4 pound weight gain over the past 1 week HEENT: no papilledema, no facial edema, PERRLA, EOMI, sclera is non-icteric, Fundi appear normal including optic discs and vessels, no signs of nystagmus. This study source was downloaded by 100000830772748 from CourseHero.com on 05-09-2022 09:24:30 GMT -05:00 https://www.coursehero.com/file/79666832/I-human-soap-note-tina-sandler-docx/ CV: displaced PMI, +1 pitting edema to knees Lungs: CTAL, tympanic throughout fields GI: Appropriately gravid, fetal heart rate 142, fundal height 32 CM, fetal movement detected, no rebound tenderness, no notable guarding, no tympany or shifting dullness GYN: cervix closed and long, no vaginal discharge or leakage, no adenexial tenderness or mass Skin: tightness around wedding band, pants, and shoes, pedal edema +1, +1 pretibial edema to knees, no bruising noted M/S: no rigidity, normal bulk and tone, ROM equal and normal b/l, normal stability, 5/5 muscle strength in all extremities Neuro: CN 1-12 intact Psych: answering questions appropriately, pleasant Assessment Diff dx: The primary: mild preeclampsia met by SBP >140 or DSP >90 plus proteinuria 300mg/24 hours or >1+ on dipstick (August and Sibai, 2020) 1) - Preeclampsia is a multisystem progressive disorder characterized by the new onset of hypertension and proteinuria. Your BP was elevated 146/90 with +1 proteinuria on your urine dipstick. - You meet the criteria for mild preeclampsia. You will need close monitoring - Due to the mild nature of the BP rise, the plan will be to monitor F/U: - We recommended you two be admitted to the hospital for observation but refused, Please come into the clinic twice weekly for close monitoring for progressive preeclampsia (August and Sibai, 2020). - Come in urgently if you develop any of the following symptoms (August and Sibai, 2020)  Worsening headaches  Epigastric pain  Visual changes  RUQ pain  Nausea vomiting  Worsening edema 2) Headaches - Continue to take Tylenol as that has been effective - Partake in stress reliving activates such as walking, deep breathing exercises, and calm environments 3) Acid reflux- (American Pregnancy Association, 2018) - Heartburn and indigestion are more common during the third trimester because the growing uterus puts pressure on the intestines and the stomach. The pressure on the stomach may also push contents back up into the esophagus. - Eat five to six smaller meals throughout the day rather than three large meals - Wait an hour after eating to lie down - Avoid spicy, greasy, and fatty foods This study source was downloaded by 100000830772748 from CourseHero.com on 05-09-2022 09:24:30 GMT -05:00 https://www.coursehero.com/file/79666832/I-human-soap-note-tina-sandler-docx/ - TUMS (calcium carbonate) 2-4 tabs PO prn; max 10 tabs/24h if pregnant (epocrates, 2020) August, P., & Sibai, B. (2020, June 26). Preeclampsia: Clinical features and diagnosis. Retrieved November 12, 2020, from https://www.uptodate.com/contents/preeclampsia-clinicalfeatures-and-diagnosis Epocrates. (2020). Retrieved November 12, 2020, from https://online.epocrates.com/drugs/otcs/187601/Tums/Dosing American Pregnancy Association. (2018, April 02). Heartburn During Pregnancy: Causes and Treatment. Retrieved November 12, 2020, from https://ameri [Show More]

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