A 34-year-old woman presented to the clinic 35 weeks pregnant, she has fatigue that started earlier in her pregnancy, dyspnea on exertion, and is restless during sleep. She has a history of menorrhagia, and a previous preterm delivery due to severe preeclampsia. Her pulse is103; BP- 140/90 CBC with leukocytes, 10.8 × 109/L; Hb, 8.9 g/dL; HCT- 28.4%; MCV- 72 fL, platelets- 272 × 109/L, RBC- 18. 4 weeks earlier it was (for Hb, 8.5- Hct, 26.8%, MCV-78 ), oral iron had been started by an OB but it caused a lot of constipation.
With this patient in mind, address the following in your Focused Note Template:
- Subjective: What details did the patient provide regarding her personal and medical history?
- Objective: What observations did you make during the physical assessment?
- Assessment: What were your differential diagnoses? Provide a minimum of three possible diagnoses. List them from highest priority to lowest priority. What was your primary diagnosis and why?
- Plan: What was your plan for diagnostics and primary diagnosis? What was your plan for treatment and management, including alternative therapies? Include pharmacologic and nonpharmacologic treatments, alternative therapies, and follow-up parameters, as well as a rationale for this treatment and management plan.
- Reflection notes: What would you do differently in a similar patient evaluation?
Subjective: The patient is a 34-year-old pregnant woman who presented to the clinic at 35 weeks of gestation with complaints of fatigue that started earlier in her pregnancy, dyspnea on exertion, and restlessness during sleep. She also has a history of menorrhagia and a previous preterm delivery due to severe preeclampsia.
Objective: During the physical assessment, the patient’s vital signs were recorded with a pulse of 103 and a blood pressure of 140/90. Her complete blood count (CBC) showed leukocytes of 10.8 × 109/L, hemoglobin (Hb) of 8.9 g/dL, hematocrit (HCT) of 28.4%, mean corpuscular volume (MCV) of 72 fL, and platelets of 272 × 109/L. The patient’s red blood cell (RBC) count was also elevated at 18.4, and her previous CBC taken 4 weeks earlier showed Hb of 8.5, HCT of 26.8%, and MCV of 78.
Assessment: The patient’s symptoms and laboratory findings suggest several possible diagnoses, including anemia, iron deficiency, and preeclampsia. Anemia and iron deficiency are common during pregnancy and could be the cause of the patient’s fatigue, dyspnea on exertion, and restless sleep. Preeclampsia is also a concern, given the patient’s history of preterm delivery due to severe preeclampsia and her elevated blood pressure.
- Iron deficiency anemia
- Anemia of chronic disease
Primary diagnosis: Based on the patient’s history of preterm delivery due to severe preeclampsia and elevated blood pressure, the primary diagnosis is likely to be preeclampsia.
Plan: Further diagnostic tests will include a 24-hour urine collection for proteinuria, liver function tests, and a non-stress test to assess fetal well-being. The patient will also be closely monitored for signs of worsening preeclampsia, including headaches, vision changes, epigastric pain, and hyperreflexia. If the patient’s preeclampsia worsens, delivery may be necessary to prevent maternal and fetal complications.
In terms of treatment and management, the patient will be started on antihypertensive medication to control her blood pressure and prevent further complications. If the patient’s anemia is severe, intravenous iron therapy may be considered. The patient will also be advised to rest and avoid exertion, and close monitoring for complications and fetal well-being will continue until delivery.
Reflection notes: In a similar patient evaluation, it is important to inquire about the patient’s dietary intake of iron and any other supplements or medications that may affect iron absorption. It may also be useful to discuss the potential side effects of iron supplementation and address them promptly if they occur. Additionally, closer monitoring of the patient’s blood pressure and urine protein may be necessary to prevent the progression of preeclampsia.