Kita Brown is a 36-year-old G1 P0 black female presenting to her local urgent care with
headache and stating her mother took her blood pressure and it was a “little higher than it
should be”. Kita has had an unremarkable pregnancy, which was conceived thru IVF. She is
currently 30 5/7 weeks pregnant and relates she has had no problem with her pregnancy. She
only takes prenatal vitamins, and relates she was on hctz prior to pregnancy for borderline BP
but stopped it when she underwent IVF and her BP has remained “pretty normal”. Sher relates
she was prescribed po labetalol but did not take it regularly as she didn’t want to take anything
that might hurt the baby.
Her initial prenatal screening, including initial labs, and third trimester CBC and glucose testing
have been normal. She additionally at her 1st prenatal visit had baseline PIH (pregnancy
induced hypertension/pre-eclampsia) due to her history of hypertension which were normal
including a protein to creatine ratio.
Upon intake at the urgent care the notes relate she appears in no apparent distress, and she
has reported fetal movement within the past hour. She denies, any other symptoms including
epigastric pain, vision changes or nausea. She states fetal movement has been normal, and
denies leaking fluid, vaginal bleeding, or contractions. She relates slight swelling and her weight
gain date has been 17 lbs. Current BMI is 25.1. BP is 162/90, pulse 82, respirations 16 and
unlabored, temperature 98.2 orally. Kita was transferred to the emergency room due to her
complaints and her gestational age.
Upon arrival to the emergency room 30 minutes later her repeat BP was 166/ 88. It was retaken
15 minutes later and was 162/92. All blood pressures were confirmed with a manual cuff. She
had no additional complaints.
Based on your assigned case study, post a Focused SOAP NOTE with the following:
Differential diagnosis (dx) with a minimum of 3 possible conditions or diseases.
Define what you believe is the most important diagnosis. Be sure to include the first priority in conducting your assessment.
Explain which diagnostic tests and treatment options you would recommend for your patient and explain your reasoning.
Your differential diagnosis, what you believe the most important diagnosis is and why, additional diagnostic tests and treatments and rationales are what this assignment and grading is focused on.
