Initials: J.K.
Age: 39
Sex: F
Race: Caucasian

Health Care Profile

Medications and Med Synthesis: Tramadol 50 mg prn

Allergies: NKDA

Reason for Contact: annual exam and pap smear History of Present Illness: Last pap was 10 years ago and was abnormal. Patient has been having heavy but regular periods for the past year. Bleeding seems to be worsening monthly. Patient reports y days of bleeding with the first 2-3 so heavy that she is soaking through a super plus tampon and pad hourly day and night. She is fatigued all of the time but has increased fatigue the week of her cycle. She has large clots and very heavy cramping and back pain associated with cycles. She denies having a history of anemia aside from during pregnancy. She does feel occasionally dizzy or lightheaded with position changes the week of her cycle.

Past Medical History

Childhood illnesses: denies measles, mumps, rubella, varicella, rheumatic fever, and pertussis

Major illnesses: none

Hospitalizations and surgeries: History of Catheter Ablation Atrial Supraventricular Tachycardia 2012.

Significant injuries: denies

Health Maintenance

General health screening: a. Frequency of dental exams/treatment: biannual exam & cleaning; most recent: 5/2015 b. Last eye exam: 4/2015 c. Colonoscopy and rectal exam: not performed d. Lab work: denies any lab work for the past 10 years e. Immunizations: Reports TDaP in 8/2013; received all routine childhood Immunizations.

Substance use a. ETOH: denies b. Tobacco: denies c. Street drugs: denies

Family History

Family History of: a. HTN: mother b. Heart disease: denies c. Hypercholesterolemia: maternal grandfather d. Hypothyroidism: mother e. Cancer: denies f. Diabetes mellitus: mother g. Alcoholism: mother and father h. Mental health disorders: mother and sister – Bipolar Disorder i. Stroke/PVD: maternal grandfather j. Allergies: Cefzil and Neurontin k. Kidney disease: denies

Review of Systems

Skin: Denies rashes, lumps, sores, itching, dryness, changes in color; changes in hair or nails; changes in size or color of moles.

Hair: Denies alopecia/hirsutism, texture/appearance changes.

Head and face: Denies head injury, dizziness, lightheadedness, facial/neck pain, or swollen glands. Does experience “some” lightheadedness with position changes the week of her cycle. Denies persistent headaches. Denies any visual changes or disturbances.

Eyes: Denies use of glasses or contacts. Denies pain, redness, swelling, trauma, excessive tearing/drying, discharge, double or blurred vision, spots, specks, flashing lights, blind spots, glaucoma, cataracts or other changes in visual fields/acuity.

Ears: Denies hearing loss, tinnitus, vertigo, earaches, infection, discharge or use of hearing aids.

Nose and Sinuses: Denies frequent colds, nasal stuffiness, discharge, or itching, hay fever, nosebleeds, or sinus trouble.

Mouth and Throat: Denies any recent cavities; brushes and flosses twice daily; Denies soreness, lesions, bleeding, sores, toothache, sore throat, dryness/excessive salivation, hoarseness, or use of prosthetic devices.

Neck and Nodes: Denies tenderness, pain, stiffness, masses, or swollen glands.

Breasts: Denies change in size/appearance, masses, swelling, tenderness, pain, or discharge.

Respiratory: Denies cough, wheezing, asthma, bronchitis, pneumonia, sputum production, hemoptysis, and dyspnea.

Cardiac: Denies chest pain/discomfort, palpitations, edema, orthopnea, paroxysmal nocturnal dyspnea. History of a ablation for Atrial Supraventricular Tachycardia in 2012. Denies SVT sensations since that time.

Gastrointestinal: Describes appetite as good. Denies dysphagia, odynophagia, nausea, vomiting, diarrhea, hemorrhoids, abdominal pain, excessive gas/belching, jaundice, liver, or gallbladder trouble. Complains of intermittent constipation but it is controlled with diet or Milk of Magnesia PRN.

Urinary: Denies urgency, dysuria, hematuria, hesitancy, or incontinence with sneezing, coughing, laughing or other activity. Abdominal, flank pain, suprapubic pain, and ureteral colic denied. Denies polyuria or nocturia.

Genitoreproductive: Complains of increased heavy menses, large clots, heavy cramping, and back pain associated with cycles. Cycles occur approximately every 28 days. The duration of her recent periods have been regular and usually last 6 days. G3 P (A2 L1)

Peripheral Vascular: Denies claudication, leg cramps, and varicose veins, past clots in the veins, swelling in calves, legs or feet, color or change in fingertips or toes during cold weather, or swelling with redness or tenderness.

Musculoskeletal: Denies birth trauma and family history of skeletal or genetic problems. Denies any clumsiness, limping, gait abnormalities, muscle or joint pain, stiffness, arthritis, gout, backache, limitation of motion or activity at muscles or joints. Denies joint pain with systemic features such as fever, chills, rash, anorexia, weight loss, or weakness. Denies history of trauma or falls. Reports ability to manage all ADL’s with no physical limitations.

Hematologic: Denies anemia, easy bruising or bleeding, past transfusions.

Endocrine: Denies heat or cold intolerance, excessive sweating, excessive thirst or hunger, polyuria.

Psychological: Denies stress at home or work. Denies depression, guilt, hallucinations, and problems with sleeping. Reports feeling tired and having little energy.

Physical Exam

Height: 62 inches
Weight: 218 lbs
BMI: 39.92
Temp: 98.7
HR: 84
RR: 18
BP: 120/80

General Appearance: Alert, pleasant, oriented X 4, gait adequate, dress appropriate, clean

Skin: Warm, smooth, soft, dry, intact without lesions or rashes. No pallor, cyanosis, increased brown pigmentation, loss of pigmentation, redness, or yellowing of the skin noted. Mobility and turgor adequate.

Hair: Thin, brown, soft hair even distributed across scalp. No evidence of alopecia, trichotillomania, redness, scaling, infestation, or dander. No lesions or nodules noted on scalp.

Nails: Rectangular, clean fingernails, curvature approximately 180 degrees or less, lunula normal, absent of lesions, no clubbing, capillary refill less than 2 seconds.

Head, Face, & Neck: Normocephalic. No deformities, lumps or tenderness noted to the skull. No asymmetry, involuntary movements, edema, or masses noted to the face. Neck, trachea, thyroid midline without tenderness. No asymmetry, masses, or scars. No tenderness, erythema, or evidence of lymphadenopathy on palpation of pre/post-auricular, submandibular, submental, occipital, tonsillar, cervical, or clavicular lymph nodes.

Eyes: Thick everted lashes without evidence of crusting. Lids symmetric. No protrusion, ptosis, erythema, lesions, or edema. Conjunctiva pink, not pale or injected. No excessive tearing or drying. Smooth, pink bulbar and palpebral conjunctiva. Sclera white, cornea clear- both without evidence of swelling, scarring, arcus, trauma or lesions. Irises uniformly brown and no shadows noted. Pupils PERRLA (direct & consensual) at 4mm bilateral. Pupillary and consensual reaction to light normal. Extra ocular movements intact without evidence of nystagmus or lid lag.

Ears: Bilateral auricles inspected and present without pain, deformities, lumps, or skin lesions. Mastoid process palpable with no tenderness noted. No discharge, odor, foreign bodies, cerumen, redness of the skin or swelling noted to bilateral ear canals. Landmarks visible. Bilateral tympanic membranes visualized translucent, flat, pearl gray. No perforations. Cone of light reflex at 5(right) and 7(left) o’clock.

Mouth & Pharynx: Lips pink and moist without lumps, ulcers, cracking, or scaliness. Oral mucosa pink and absent of ulcers, white patches, and nodules. Gums pink without brown patches. No swelling or ulceration to the gum margins. Teeth clean and white with no obvious caries or absent teeth. Hard palate pink and no lesions visible. Tongue symmetric. No white or reddened area, nodules, or ulcerations on the sides, ventral of tongue, or sublingual area. Saliva adequate. No lesions visible at hard/soft palate. Uvula visible without erythema/edema, rises midline. Tonsils +1. No exudate noted on oropharynx.

Breasts: Breasts symmetric, smooth, without masses. Nipples absent of discharge.

Heart & peripheral vasculature: Heart rate 84 and regular rhythm. S1 and S2 auscultated. No S3, S4, murmurs, snaps, clicks, or friction rubs heard during systole or diastole. No mitral murmur heard with patient positioned on left side. No aortic murmur heard with patient sitting forward. Pulses at carotid, brachial, radial, ulnar, and popliteal, posterior tibial, and dorsalis pedis palpated and 2+ bilaterally. Trace lower extremity edema noted; no varicosities. Patient is pink in color, no cyanosis or clubbing of the nails noted. Fetal Heart rate obtained and was 154 and regular.

Respiratory: Respirations appear comfortable and relaxed without nasal flaring or use of accessory muscles/retraction of intercostal spaces. 18 respirations per minute. No dyspnea, orthopnea, tachypnea, or hypopnea. Chest expansion bilaterally symmetric. Thorax symmetrical on inspiration/expiration with normal Anterior Posterior ratio of 1:2. No tenderness with palpation. Posterior chest wall percussion resonant throughout. Lungs clear throughout all fields on auscultation with no adventitious breath sounds noted. Lungs sounds auscultated to upper, middle, and lower lobes on right and left, both anterior and posterior.

Abdomen: Fundal height measuring 40.

GU: deferred

Musculoskeletal: Joints and muscles symmetric; no swelling, masses, deformities; normal spinal curvature. Muscle strength – able to maintain flexion against resistance and without tenderness. Muscles symmetric without evidence of wasting or tenderness with palpation.

Neurological: alert, oriented x 4, relaxed, cooperative, behavior and speech appropriate, cognitive and intellectual function appropriate. Gait even and smooth. Movements purposeful and coordinated without tremor.

Problem List:

Differential Diagnosis: 1. Transient Hypertension – blood pressure that is elevated temporarily and later returns to normal. 2. Pregnancy Induced Hypertension – blood pressure greater than 140/90 measured on two separate occasions, more than 6 hours apart, without the presence of protein in the urine and diagnosed after 20 weeks gestation. 3. Preeclampsia – gestational hypertension plus proteinuria. Severe preeclampsia involves a blood pressure greater than 160/90, with additional medical signs and symptoms. HELPP syndrome is a type of preeclampsia. It is a combination of three medical conditions: hemolytic anemia, elevated liver enzymes, and low platelet count. 4. Hypothyroidism

Diagnosis: Hypothyroidism and Transient Hypertension. Patient’s hypothyroidism was diagnosed prior to pregnancy. TSH is within normal range so she should remain on the 200 mcg of Levothyroxine and provider should continue to check her TSH levels every 6-8 weeks. Provider will continue to monitor for side effects of Levothyroxine. This patients’ most likely diagnosis is transient hypertension. After resting, the patient’s blood pressure returned to normal range but continued to be borderline high.

Treatment Plan: A urinalysis was obtained but was WNL and negative for protein. Lab work was obtained. A CBC, CMP, Uric Acid level, INR/PT, PTT, and a Fibrinogen was obtained. All were WNL. Lab work was obtained to rule out infection, dehydration, protein, elevated liver enzymes, kidney function, and preeclampsia or HELPP syndrome. A Non Stress Test was obtained and was reactive for fetal activity. Patient is to follow up with Obstetrician on 7/31. Patient is also to have her blood pressure checked BID and to phone provider with results. Patient is to call or return with any changes such as vision disturbances, increased swelling, increased sense of fatigue, flu like symptoms, shortness of breath, feeling of increased heart rate, abdominal pain, or increased headaches. Dependent upon what her blood pressure reveals in two days or sooner with problems, provider will obtain another urinalysis, lab work, non-stress test, biophysical profile, and send to labor and delivery for further monitoring of blood pressures and baby.

A fetal non stress test (NST) is a simple non-invasive test performed in pregnancies greater than 28 weeks gestation. The test involves attaching one belt to the mother’s abdomen to measure fetal heart rate and another belt to measure contractions. Movement, heart rate, and reactivity of heart rate to movement is measured for 20-30 minutes. A NST test may be performed if a sense of decreased fetal movements, overdue, suspicion that the placenta is not functioning adequately, or at high risk for any reason. This test can indicate if the baby is not receiving enough oxygen because of placental or umbilical problems or other signs of distress.

A Biophysical profile (BPP) measures the health of the fetus during pregnancy. A BPP test may include a non-stress test with electronic fetal monitoring and a fetal ultrasound. A BPP measures the baby’s heart rate, muscle tone, movement, breathing, and the amount of amniotic fluid around the baby.

Overall, this patient will require careful follow up over the remainder of her pregnancy. She is scheduled for a cesarean section on 8/18/15. This careful monitoring will be to ensure this hypertension does not develop into preeclampsia or HELPP syndrome.

References

Cunningham, Leveno, Bloom, Hauth, Rouse, & Spong (2010). Williams Obstetrics (23rd Ed.). New York, NY: McGraw Hill Medical.
Lexicomp
Mahan Buttaro, T., Trybulski, J., Polgar Bailey, P., & Sandberg-Cook, J. (2013). Primary Care A Collaborative Practice (4th Ed.). United States of America: Elsevier.
Seller, R. H., & Symons, A. B. (2007). Differential Diagnosis of Common Complaints (6th Ed.). Philadelphia, PA: Elsevier.