Nancy, 34-years-old, presents for her 32-week appointment.
She has been feeling run down and has been having increased headaches that
Tylenol is not relieving. Urine specimen has been obtained and she has 1+
protein. Her blood pressure is 165/100 mmHg, pulse 74, respirations 12,
temperature 99°F, and her weight is 167 lb. She states she is taking her
prenatal vitamins, the baby moves fine, and denies leakage of fluids,
contractions, and vaginal bleeding. Her exam reveals fetal heart tones 143 bpm,
fundal height 34 cm.
1.
What history should be gathered?
2.
What labs should be collected at this time?
3.
What are your differential diagnoses for this
patient at this time?
4.
What interventions, if any, should be taken at
this time?
Rubric
Complete and accurate subjective history – 25 points
Appropriate labs obtained and reason for labs – 25 points
At least three differential diagnoses listed with supporting evidence – 20
Appropriate pharmacologic and nonpharmacologic treatment with patient education – 20
APA format – 10
