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I human OBGYN Tina Sandler - Part 3-Case study
Tina Sandler – PART 3 – OBGYN
CC – high blood pressure
Diagnosis –preeclampsia 4asc/1hpi
HTN, heartburn, headaches(stress?), hand/feetswelling, fetus alive
Tests- UA, CBC, CMP, Creatinine 24hr
Problem Statement:
( Demographic description – chief complaint – Hx and PE key findings – risk factors )
Tina Sandler is a 29-year-old female G5P2111 here at 33 weeks(third trimester) for evaluation of High
blood pressure (146/90), having missed visits after being seen at 24 weeks gestation. Increased
frequency of headaches, as well as heartburn. BP is 146/90 increased from last visit, fundal height
appropriate for gestation, FHT=not detected, however fetal movements detected on PE, No bruising
noted. Edema is present: +1 pedal edema and +1 ankle edema with edema in hands as well.
CC: Tina Sandler is a 29-year-old female G5P2111 here at 33 weeks(third trimester) for evaluation of
High blood pressure (146/90)
HPI: Patient reports she checked her BP at a pharmacy and it came out high. She has missed her f/u
visits and now reports continued headaches triggered by relationship stress, as well as heartburn and
edema of her extremities
Meds: Prenatal vitamins
PMH: Patient has a history of ectopic pregnancy and preeclampsia and 3rd trimester loss of pregnancy.
SH: Patient reportsthatshe is not currently smoking cigarettes, drinking alcohol, or using recreational
drugs while pregnant
ROS: Only positive findings are seen in HPI
Physical Exam:
VS: Pulse – 82; BP – 146/90 (138/82 standing) RR – 18; T – 97.4F (36 C); SpO2 – 94%
Extremities: +1 pedal edema, +1 pretibial edema to knees, also finger edema.
ASSESSMENT/PLAN
Test Results:
• Urinalysis: Proteinuria +1
• CBC: Slight elevation in WBC
• CMP: Normal
• Creatinine, urine 24hour: Normal
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