Case Study Pregnant Patient With Pre-eclampsia Essay Paper

Pre-eclampsia Pregnancy

 Subjective

CC: Swelling, headaches, visual abnormalities, and sporadic contractions that are alleviated by resting.

HPI: N.D is a 29-year-old African American female, primigravida, para 0-0-0-0, who comes for an OB checkup at 32 weeks of pregnancy. The patient has reported that her hands are swollen on a daily basis, that she had a headache four days last week that she ranked as 7/10 in pain, and that she has pain in the temporal region. She did notice that her vision was a little blurry one day last week, but she says that her optometrist had informed her that some expectant mothers can have vision abnormalities, so she didn’t think much of it. Good baby movement is reported, as well as sporadic contractions that increase but subside after 5 minutes of rest; there is no pattern to the contractions and they are inconsistent in frequency Case Study Pregnant Patient With Pre-eclampsia Essay Paper.

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Past Medical/Surgical History/Allergies:

History of PCOS 2 years ago, resolved with birth control pills. No other major medical history. Denies surgical history. Patient is current on immunizations. Denies medication, food, latex or seasonal allergies.  Current medications include Multivitamin 1 PO QD.

Associated risk factors/demographics: Risk factors for N.D’s case include: being African American, being pregnant for the first time, and history of obesity.

Objective

Vital Signs: HR 90, BP 177/73, RR 17. Height: 5’6; Weight: 225 lbs, SPO2: 99%, Temp” 98.5 F

Physical Assessment: On physical examination, N.D appeared alert, oriented, and in no acute distress. She appeared well-nourished and was dressed appropriately. The rest of her physical exam revealed no abnormalities, except for Edema bilateral hands 1+.

Diagnostic Testing:

CBC, serum creatinine level, liver tests (ALT, LDH, AST), and urinary protein determination (protein: creatinine ratio or 24-hour urine protein).

Urinalysis.

Ultrasound- amniotic fluid volume determination.

Non stress-test- baby’s heart rate reaction to movement determination.

Differential Diagnoses: Preeclampsia with severe features, superimposed preeclampsia, and Pheochromocytoma Case Study Pregnant Patient With Pre-eclampsia Essay Paper.

In this particular case study, there are three differential diagnoses to consider: Preeclampsia with severe features, superimposed preeclampsia, and Pheochromocytoma. These are defined in the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5). While these disorders are similar in regard to causing hypertension during pregnancy, they have varying degrees of differences. Preeclampsia with severe features is defined as the occurrence of one or more of the following indicators in the context of preeclampsia: the patient’s SBP must be more than 160 mm Hg or his or her DBP must be greater than 110 mm Hg on two separate occasions at least 4 hours apart when the patient is on bed rest, impaired hepatic function, progression of renal insufficiency, visual or celebral abnormalities, and pulmonary edema (Norwitz & Funai, 2020). Common symptoms of this condition include severe headaches, visual changes, proteinuria, nausea or vomiting, and decreased urine output.  Superimposed preeclampsia is defined as a severe worsening of underlying essential hypertension in women who are in the last half of their pregnancy (August, et al., 2020). The symptoms of this condition are similar to those of preeclampsia with severe features. Pregnancy-related pheochromocytoma may have serious consequences for both the mother and the baby. Because of its unclear appearance, it is often mistaken for pre-eclampsia, and it may mimic a variety of other pregnancy-related problems (August, et al., 2020). Pheochromocytoma symptoms usually appear during the third trimester of pregnancy and are caused by an excess of catecholamines. Patients may complain of headaches, sweating, dizziness, dyspnea, palpitations, nausea, vomiting, and abdominal pain.

Relevant testing and national guidelines recommendations:

Guidelines for the management of preeclampsia were developed by the National Institute for Clinical Excellence (NICE). These guidelines include provisions for evaluating risk based on evidence, establishing explicit criteria for referral to specialized facilities, and establishing a schedule for monitoring women in the community after 20 weeks of pregnancy (Lassi et al., 2015). In addition, the criteria for referral for step-up treatment are highlighted. According NICE, the evaluation of risk is the most critical first step toward a diagnosis of preeclampsia in community settings.

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In regard to the diagnosis of pheochromocytoma, the Endocrine Society Clinical Guidelines propose that the first biochemical testing for PPGLs should include measures of plasma free or urinary fractionated metanephrine levels (Lenders et al., 2016). Preanalytical variables that might contribute to false-positive or false-negative findings should be taken into account. All favorable outcomes need further investigation. CT scans are recommended for initial imaging, while magnetic resonance imaging is preferable in individuals with metastatic illness or when radiation exposure must be kept to a minimum Case Study Pregnant Patient With Pre-eclampsia Essay Paper.

References

August, P., & Sibai, B. M. (2017). Preeclampsia: Clinical features and diagnosis. Post TW, UpToDate. Waltham, MA: UpToDate. https://www.uptodate.com/contents/preeclampsia-clinical-features-and-diagnosis

Lassi, Z., Salam, R., Das, J., Ali, A., & Bhaumik, S. (2015). Diagnosis and management of preeclampsia in community settings in low and middle-income countries. Journal of Family Medicine and Primary Care, 4(4), 501. https://doi.org/10.4103/2249-4863.174265

Lenders, J. W., Duh, Q., Eisenhofer, G., Gimenez-Roqueplo, A., Grebe, S. K., Murad, M. H., Naruse, M., Pacak, K., & Young, W. F. (2016). Pheochromocytoma and Paraganglioma: An Endocrine Society clinical practice guideline. The Journal of Clinical Endocrinology & Metabolism, 99(6), 1915-1942. https://doi.org/10.1210/jc.2014-1498

Norwitz, E. R., & Funai, M. E. F. (2020). Expectant management of preterm preeclampsia with severe features. https://www.uptodate.com/contents/preeclampsia-with-severe-features-expectant-management-remote-from-term

Pre-Eclampsia in Pregnancy

Demographics and Chief Complaint (CC)

  • The patient in this case is an elderly African American (AA) primigravida aged 38 years.
  • She is at a gestational stage of 34 weeks and presents with complaints of severe headaches, nausea, vomiting, photophobia, right upper quadrant abdominal pain, oliguria, pedal edema, and confusion.
  • On examination, her blood pressure is 140/95 mmHg.

Past Medical and Surgical History/ Risk Factors

  • The patient has had isolated cases of slightly elevated blood pressure indicating a pre-hypertensive state.
  • She has however never been diagnosed with hypertension. During antenatal visits, the patient had been noted to be overweight with a body mass index or BMI of 26.3 kg/m2.
  • She had been advised on diet and exercise to help lower her weight. The patient has no other significant medical history. She had a herniorraphy done when she was 28 years old.
  • The associated risk factors for pre-eclampsia include pre-gravid history of hypertension, having the first pregnancy, being a woman over 40 years, obesity, being African American, and in-vitro fertilization amongst others (Burton et al., 2019).

Lifestyle and Allergies

  • The patient denies any allergies to medications, food, or environmental allergens.
  • She is a former air hostess and currently a receptionist in a five star hotel.
  • She is a social drinker often over the weekends with friends but never smokes.
  • Her lifestyle is pretty much sedentary although she often enjoys nature walks over the weekends when she is not working.
  • Her hobbies include cooking, travelling, and watching movies.

History of Presenting Illness (HPI)

  • The patient is an AA female aged 38 with complaints as above. She denies any previous history of the same.
  • The current symptoms started one week ago into the 34th week of gestation. The symptoms are on and off but very frequent in occurrence.
  • They are characteristically severe and are aggravated by standing and cold.
  • Relief comes by taking blood pressure medications such as hydralazine (Katzung, 2018; Rosenthal & Burchum, 2018) and having bed rest.
  • She rates the symptom severity at 7/10. Case Study Pregnant Patient With Pre-eclampsia Essay Paper

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Differential Diagnosis

  • Three differential diagnoses for pre-eclampsia are gestational thrombocytopenia, chronic hypertension, and systemic lupus erythematosus or SLE (Hammer & McPhee, 2018; Huether & McCance, 2017). These three differ in that:
  • The pathophysiology of chronic hypertension is an elevated blood pressure reading on several occasions before 20 weeks of gestation without an obvious cause.
  • For gestational thrombocytopenia it is accelerated platelet activation and consumption with reduced lifespan.
  • In SLE it is activation of the body’s immune system against its own cells (Hammer & McPhee, 2018; Huether & McCance, 2017)Case Study Pregnant Patient With Pre-eclampsia Essay Paper.
  • The presentation of the three is similar in as far as the generic symptoms nausea, vomiting, and headaches are concerned.
  • Other presentations such as edema and elevated blood pressure do not cut across the differential diagnosis spectrum.
  • Diagnostic testing for gestational thrombocytopenia is a complete blood count (CBC), for chronic hypertension it is blood pressure reading, and for SLE it is antinuclear antibody titre (Hammer & McPhee, 2018; Huether & McCance, 2017).
  • The practice guidelines are the administration of low-dose acetylsalicylic acid or ASA (aspirin, 75 mg) before 20 weeks of gestation (Katzung, 2018; Rosenthal & Burchum, 2018).
  • The national guidelines on diagnostic testing require diagnosis using the tests as stated above.  

References

Burton, G.J., Redman, C.W., Roberts, J.M., & Moffett, A. (2019). Pre-eclampsia: Pathophysiology and clinical implications. BMJ, l2381. https://doi.org/10.1136/bmj.l2381

Hammer, D.G., & McPhee, S.J. (Eds). (2018). Pathophysiology of disease: An introduction to clinical medicine, 8th ed. McGraw-Hill Education.

Huether, S.E. & McCance, K.L. (2017). Understanding pathophysiology, 6th ed. Elsevier, Inc.

Katzung, B.G. (Ed) (2018). Basic and clinical pharmacology, 14th ed. McGraw-Hill Education.

Rosenthal, L.D., & Burchum, J.R. (2018). Lehne’s pharmacotherapeutics for advanced practice providers. Elsevier. Case Study Pregnant Patient With Pre-eclampsia Essay Paper

Topic: Pre-eclampsia pregnancy. Need a case study outline for a made up patient that presents all the requirements below. Chief complaint, PMHx, Demographics, PSHx, allergies, lifestyle, HPI Associated risk factors/demographics that contribute to the chief complaint and differential diagnoses Three common differential diagnoses represented by the CC including pathophysiology and rationale in the identified body system i.e., if pulmonary was your body system than a chief complaint could be persistent cough and three pulmonary differentials; Discuss how the three differential diagnoses differ from each other in: occurrence, pathophysiology and presentation (NOTE: Simply listing the diagnoses and their occurrence, pathophysiology and presentations separately does not confer an understanding of how they differ. Your discussion should compare and contrast these items against each other among the three differentials chosen); Relevant testing required to diagnose/evaluate severity of the three differential diagnoses; and Review of relevant National Guidelines related to the Diagnosis and Diagnostic testing for these diagnoses Case Study Pregnant Patient With Pre-eclampsia Essay Paper