NRNP 6552 Kita Brown Soap Note
Case Study: Hypertension in Pregnancy
For the NRNP 6552 Kita Brown Soap Note assignment, Kita Brown is a 36-year-old G1 P0 black female presenting to her local urgent care with a headache and stating her mother took her blood pressure, which 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 has had no problem with her pregnancy. She only takes prenatal vitamins and describes she was on hctz before pregnancy for borderline BP m but stopped it when she underwent IVF, and her BP has remained “pretty normal.” She relates she has been prescribed 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 expected. , Additionally, at her 1st prenatal visit, she had baseline PIH (pregnancy-induced hypertension/pre-eclampsia) due to her history of hypertension, including an average protein-to-creatine ratio.
Upon intake at the urgent care, the notes relate that she appears in no apparent distress and has reported fetal movement within the past hour. She denies other symptoms, including epigastric pain, vision changes, or nausea. She states fetal movement has been expected and denies leaking fluid, vaginal bleeding, or contractions. She relates slight swelling, and her weight gain date has been 17 lbs. Her 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 gestational age.
Upon arrival at the emergency room 30 minutes later, her repeat BP was 166/ 88. It was retaken
Fifteen 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 at least three possible conditions or diseases.
- Define what you believe is the most critical diagnosis. Be sure to include the priority in conducting your assessment.
- Explain which diagnostic tests and treatment options you recommend for your patient and your reasoning.
This assignment and grading are focused on your differential diagnosis, what you believe the most critical diagnosis is and why, additional diagnostic tests and treatments, and rationales.