Clinical Presentation & Protocol
Patient Usually Complains Of
Patient presents at [gestational age] weeks gestation with complaints of [persistent headache/visual disturbances/epigastric or RUQ pain]. Blood pressure readings noted at [BP1] and [BP2] mmHg, taken at least 4 hours apart. Patient denies vaginal bleeding or leakage of fluid. Fetal movement is reported as [normal/decreased].
Clinical Examination Findings
General: Patient appears [distressed/comfortable]. HEENT: No papilledema. Cardiovascular: S1/S2 regular, no murmurs. Pulmonary: Clear to auscultation bilaterally. Abdomen: Gravid uterus, fundal height [cm], fetal heart tones [bpm], tender to palpation in [RUQ/epigastric region]. Extremities: [1+/2+/3+] pitting edema noted in lower extremities. Neurological: Hyperreflexia ([+2/+3/+4]) with [present/absent] clonus.
Treatment Protocol
1. Initiate Magnesium Sulfate infusion for seizure prophylaxis per protocol. 2. Administer antihypertensive therapy (Labetalol/Hydralazine) to maintain BP <160/110 mmHg. 3. Continuous fetal heart rate monitoring. 4. Strict intake/output monitoring with Foley catheter. 5. Laboratory evaluation: CBC, LFTs, LDH, Creatinine, and Uric acid. 6. Consider corticosteroid administration for fetal lung maturity if <34 weeks.