Marietta Outreach Clinic
Patient Name: Simone Sodo Gender: Female Age: 38
Diagnosis: Chronic Hypertension in Pregnancy
Insurance: Medicaid Number # 1EG4-TE5-MK72
Insurance: Medicaid Number # 1EG4-TE5-MK72
HPI
Ms. Sodo is a 38 year old pregnant female at 32 weeks gestation who was brought to the emergency department by her husband because she was shaking and seemed to be passing out. She was “out of it” for about 15 minutes and had some urinary incontinence with the spell. He was worried and called 911. The paramedics report no further seizure activity enroute.
Simone has missed several follow up appointments with her OB. She complains of constant and severe headache. The swelling in her legs is much worse and she has gained 18 lbs in the past 2 months. She complains of blurred vision. She also is having epigastric pain with associated nausea. She was told by her OB to be on bedrest and has tried to “rest in bed” as much as she can, but has had to continue working and take care of the household and the kids. She still feels her baby moving, but it is less frequent now.
ROS
+ loss of consciousness
+ shaking
+ fatigue
+ frontal severe headache
+ anxiety
+ weight gain since 18 lbs past 2 months
+ lower extremity edema (worsening)
+ blurred vision
+ epigastric pain
+ nausea
+ decrease in fetal movement
+ pelvic pressure
no vaginal bleeding
no vaginal leaking
no cough
no CP
no SOB
no N/V/D/blood in the stool
no urinary symptoms
no fevers or chills
no numbness or tingling
no weakness
Physical Exam
Physical Exam
Temp.: 99.2° HR: 110 BP:170/110 RR:22
FHR: 170
Urine dipstick: 3+ protein, no glucose
Point of Care Ultrasound: average uterine ultrasound age 31 weeks. Normal amniotic fluid. Anterior placenta.
General: pregnant black female, somewhat agitated and irritable
Eyes: no scleral icterus
CVS: Tachycardia, regular rhythm, normal S1, S2, no S3, +S4, +2/6 systolic ejection murmur, no rubs
Lungs: clear to auscultation, no rales, rhonchi or wheezes
Abd: gravid, + bowel sounds, mild epigastric tenderness. Fundal height 31cm.
Extr: no clubbing or cyanosis. 2+ pitting bilateral lower extremity edema to knees
Neuro: alert, oriented. + hyperreflexia DTR +3, otherwise nonfocal
SSE: closed cervix, no blood