Case Study: Missed Period
Instructions
Juanita Morales is a 47-year-old G5. P5 LC 6, Hispanic female who presents to the office complaining of lower abdominal cramping, and urinary leakage for past day. She states the abdominal cramping, suprapubic, started several hours ago, is sharp, intermittent, and getting more frequent and painful. She tried Motrin but states it did not help. She had a UTI years ago and it was like this, except the incontinence.
She has been more tired for the past several months. She relates she stopped getting her period about 8-12 months ago, and relates her menopause was easy. She relates no medical or surgical history. She has no known drug allergies and takes no medications. Social history is negative for alcohol, tobacco, and recreational drugs. Her last exam was several years ago.
Vital signs: temperature 99.1, BP 140/ 82, pulse 88, respirations 12. Height is 5’ and weight 235 lbs. (BMI 45.89). A clean catch urine was obtained, and the urine dipstick showed SG 1.010, trace blood, neg nitrates, neg leukocytes, negative glucose, 3+ protein. She thinks that maybe she had some vaginal spotting several days ago, but nothing since.
Pt relates that she has had some constipation, and increased gas for past several months. She was using NFP for contraception prior to her stopping her period. No other urinary symptoms reported.
NRNP 6552 Focused SOAP Note Template WK4
Solution
Episodic/Focused SOAP Note
Patient Information:
Initials B.L., Age- 35, Sex- Female, Race- African-American
S.
CC (chief complaint): The patient was admitted to the hospital with chronic hypertension.
HPI:
Location: N/A
Onset: 8 years ago
Character: N/A
Associated signs and symptoms: severe headaches, irregular heartbeat, fatigue, vision problems
Timing: All the time
Exacerbating/relieving factors: N/A
Severity: 9/10 scale
Current Medications: labetalol 200 mg po q 8 hours, Nifedipine po
Allergies: No known drug or food allergies.
PMHx: The patient is up to date with her immunization schedule. Her last shot was the tetanus jab that she received on May, 4th 2021. She has been suffering from chronic hypertension for the last 8 years.
Soc & Substance Hx: The patient is a kindergarten teacher who enjoys her career. She is married and has two sons aged 9 and 5 years. She has a history of smoking but stopped after being diagnosed with hypertension.
Fam Hx: The patient’s mother is alive but has hypertension and hypothyroidism. The paternal grandmother succumbed to breast cancer. Her father has diabetes and apnea.
Surgical Hx: No history of surgery.
Mental Hx: No history of mental health illnesses.
Violence Hx: No history of violence or harm to self.
Reproductive Hx: The patient was pregnant and at 39 gestation weeks delivered a healthy baby girl.
ROS:
GENERAL: No weight loss, has severe headaches, weak and fatigued.
HEENT: Eyes: Blurred vision
Ears, Nose, Throat: No hearing loss, sneezing, congestion, runny nose, or sore throat.
SKIN: No rash or itching.
CARDIOVASCULAR: No chest pain, has chest pressure, or chest discomfort. Has palpitations.
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. Pregnant with a third child.
NEUROLOGICAL: Severe headaches, dizziness. No 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: Pregnant. No reports of vaginal discharge. Sexually active.
ALLERGIES: No history of asthma, hives, eczema, or rhinitis.
O.
Physical exam:
Vitals: BP 130/78, P64, Weight 160, Height 5’6″
Neurological: Severe headaches, dizziness
HEENT: Blurred vision
Cardiovascular: Chest pressure, palpitations
Diagnostic testing: urinalysis, cholesterol test, electrocardiogram, echocardiogram, ambulatory blood pressure monitoring, urine protein test, serum uric acid level, stress test, and complete blood count.
Three additional questions
- Were you on medication for high blood pressure before pregnancy?
- Were you on anti-hypertensive during your previous pregnancies?
- How do your diet and physical activity regimen look like?
Differential Diagnoses
Preeclampsia
The first differential diagnosis for the patient is preeclampsia. The condition is characterized by the development of hypertension and the prevalence of protein in urea after twenty weeks of gestation (Fox et al., 2019). Preeclampsia is an elevated blood pressure of above 140 mm Hg systolic or above 90 mm Hg diastolic. The condition is also characterized by proteinuria of 300 mg in a urine specimen within 24 hours.
Hematologic changes among patients with preeclampsia are thrombocytopenia, microangiopathic hemolysis, and hemoconcentration. Neurological changes include headaches, scotoma, blurred vision hyperreflexia, generalized seizures of eclampsia. When the patient presented to the hospital she had to be put on Labetalol 200 mg PO q 8 hours to stabilize her BP which stabilized to 130/78 after three days.
Chronic hypertension
The second differential diagnosis is chronic hypertension. Chronic hypertension is defined as blood pressure levels above 140 mm Hg /90 mm Hg before pregnancy or before 20 weeks (Magee et al., 2020). Women with chronic hypertension tend to experience different complications ranging from superimposed preeclampsia, preterm delivery, perinatal death, low birth weight, and the admission of neonatal in the intensive care unit.
Gestational hypertension
Gestational hypertension is the third differential diagnosis. It refers to a type of hypertension that begins after 20 weeks of gestation (Braunthal & Brateanu, 2019). The blood pressure levels exceed 140 mm Hg for systolic and above 90 mm Hg for diastolic pressure. The patient should have previously normal blood pressure, should have no traces of protein in the urine, and should have no manifestation of preeclampsia. Nursing literature shows that fifty percent of women who are diagnosed with gestational hypertension between the ages of 25 and 35 years are likely to develop preeclampsia.
The management of preeclampsia is aimed at optimizing the condition of the fetus. The condition is managed using antenatal corticosteroids as well as magnesium sulfate infusions (Fox et al., 2019). A single course of betamethasone which is a corticosteroid has been shown to lower the risk of perinatal death and neonatal complications like respiratory distress syndrome.
Chronic hypertension has been seen best managed using labetalol intravenous, oral or intermittent, and oral nifedipine. The patient has been put on these medications and therefore should be monitored closely to determine her response to the drugs and change in her blood pressure levels to optimize both her health and that of her unborn child.
Gestational hypertension is managed using labetalol and hydralazine which are considered first line medications. The patient was already put on labetalol and therefore would be required to continue with the dosage while taking blood pressure readings twice for monitoring. Besides the use of pharmacological agents, the patient can be educated on the need for rest especially lying on their left side, drinking adequate water, consuming less salt as well as increased prenatal checkups.
The patient’s health history indicates that she suffers from chronic hypertension which shows the need to incorporate the use of both pharmacological and lifestyle-related interventions. Besides the administration of the two drugs that she has been prescribed, it would be important to educate her about healthy dietary patterns. Since she is a new, mother, she might face limitations regarding physical activity. She should however engage in low-intensity activities like walking until she heals from childbirth.
The patient was advised on the importance of follow-up visits for monitoring her blood pressure levels and response to medication. The patient was also informed that in case her blood pressure levels exceed the recommended levels, she should seek medical help to alleviate the possibility of complications and near-death events.
Reflection
The patient understood the importance of adhering to the treatment plan to minimize complications and adverse events. The patient agrees that besides the medications she needs to exercise lifestyle modification directed towards eating a healthy diet as well as engaging in physical activity. The patient understands her health condition, factors that are associated with it as well as the importance of taking control of her life to improving her health outcomes.
References
Braunthal, S., & Brateanu, A. (2019). Hypertension in pregnancy: Pathophysiology and treatment. SAGE open medicine, 7, 2050312119843700. https://doi.org/10.1177/2050312119843700
Fox, R., Kitt, J., Leeson, P., Aye, C., & Lewandowski, A. J. (2019). Preeclampsia: Risk Factors, Diagnosis, Management, and the Cardiovascular Impact on the Offspring. Journal of clinical medicine, 8(10), 1625. https://doi.org/10.3390/jcm8101625
Magee, L. A., Khalil, A., Kametas, N., & von Dadelszen, P. (2020). Towards personalized management of chronic hypertension in pregnancy. American Journal of Obstetrics and Gynecology.