Patient Name; Age



Author: Sarah Farris, M.D.Reviewer: Gregory Polites, M.D.Case Title: Preeclampsia in a post-partum womanTarget Audience: med students, nurses, paramedics, residents, otherPrimary Learning Objectives: key learning objectives of the scenario 1. Recognize preeclampsia in a post-partum woman2. Appropriately treat preeclampsia with magnesium sulfate3. Adequately control the patient’s blood pressure4. Admit patient to OB-GYNSecondary Learning Objectives: detailed technical goals, behavioral goals, didactic points1. Review signs and symptoms of preeclampsia and eclampsia2. Review dosing and toxicity of magnesium sulfate3. Review drugs recommended for treatment of hypertension in preeclampsiaCritical Actions ChecklistCorrectly diagnose patient with preeclampsiaInitiate magnesium sulfate IVTreat HypertensionAdmit patient to OB-GYN serviceEnvironment (if using as a simulation case)Room Set Up – ED room(if used) Manikin Set Up – high-fidelity simulator, female apparel (consider maternity clothes if available), peripheral IV, magnesium sulfate, hydralazine, nifedipine, labetolol, lorazepam, normal salineProps – sinus tach ECG, CT scans, airway equipment, code blue cartDistractors – very anxious friendActors (optional)Roles – friend of patientWho may play them – any interested partyAction Role – asking repeated questions, trying to distract learner from patient management.For Examiner OnlyAuthor:Sarah Farris, M.D.Reviewer: Gregory Polites, M.D.Case Title: Preeclampsia in a post-partum womanCASE SUMMARYCORE CONTENT AREA Obstetrics, NeurologySYNOPSIS OF HISTORY/ Scenario Background The patient presents with her friend. They were shopping at a mall and the patient had onset of a severe headache and blurred vision that worsened over two hours and is now at a 6/10. She does not normally get headaches.Chief Complaint: headache, blurred visionPast medical history: no medical conditions. Patient delivered a full-term infant ten days ago, but the baby is at home and this history should not be forthcoming.Medications and allergies: Multivitamin, no allergiesFamily and social history: Father and mother with hypertension, sister with type II DM.SYNOPSIS OF PHYSICALVS: HR 105 BP 178/98 RR 18 Pulse ox: 99% on RA T 37.4 (oral)Primary exam:Airway: intactBreathing: intactCirculation: mild tachycardia with regular pulses, normal capillary refillSecondary Exam:Gen: Alert, well-nourished, mildly obese woman. Appears uncomfortable, but non-toxic appearingHEENT: Normocephalic, atraumatic, no blurring of optic discs if examinedNeck: Normal, no thyromegalyLungs: CTAB, speaking in full sentences on room airCardiac: Mildly tachycardic, rhythm regular, no M/R/GAbdomen: Abd obese with stretch marks, soft, non-tender, + BSExtremities: NormalNeurologic: GCS 15, CN II-XII grossly intact, normal strength and sensation in all four extremities. Reflexes 3+ throughoutFor Examiner Only CRITICAL ACTIONSScenario branch points/ PLAY OF CASE GUIDELINESRecognize preeclampsiaWhile the patient’s hypertension needs to be treated, the learner should discover the diagnosis to be preeclampsia by obtaining further history from the patient and friend. The husband will be available by phone if the learner requests to speak with him.Cueing Guideline: Patient’s friend can start talking about how the patient needs to get home “for the baby.” If further questioned, age of baby is ten days old. If urinalysis is ordered, it can return if learner is struggling to make a diagnosis (protein 3+).Start magnesium sulfateThe patient needs to be quickly started on magnesium sulfate.Cueing Guideline: If no magnesium given in first 10 minutes, urinalysis can come back (3+ protein) to prompt learner that this patient has preeclampsia. If still no magnesium started, patient begins to seize and does not respond to benzodiazepines or phenytoin.Treat hypertensionAppropriate treatment of hypertension should be initiated. This primarily will involve hydralazine and labetolol, with some role for nifedipine.Cueing Guideline: Patient’s blood pressure continues to increase and headache/visual changes worsen without treatment.Consult and admit patient to OB-GYN.Depending upon level of learner, may provide push-back from OB-GYN resident, who could state that the patient is safe for discharge or that the patient just needs observation in the ED.Cueing Guideline: If learner tries to discharge the patient, have her say, “I don’t feel safe going home like this.”SCORING GUIDELINES(Critical Action No.)1. Recognize preeclampsia2. Start magnesium sulfate3. Treat hypertension: hydralazine and labetolol are first line drugs.4. Consult and admit patient to OB-GYNFor Examiner Only HISTORY Onset of Symptoms: Three hours ago. Background Info:The patient presents with her friend. They were shopping at a mall and the patient had onset of a severe headache and blurred vision that worsened over two hours and is now at a 6/10. She does not normally get headaches. (If asked further questions about the headache, the patient describes the headache as dull and throbbing, frontal, worse with movement, without photophobia or phonophobia. She has never had this kind of headache before.)Chief Complaint:“My head is killing me and my vision is blurry.”Past Medical Hx:No medical problems. (Delivered a healthy female infant ten days ago, but the learner needs to ask specific questions to obtain this information.)Past Surgical Hx:None.Habits:Smoking: Quit eight months ago. (“Why did you quit?” getsresponse “I found out I was pregnant.”ETOH: Rare.Drugs: NoneFamily Medical Hx: Mother with non-insulin dependent diabetes mellitusSocial Hx:Marital Status: MarriedChildren: TwoEducation: Some collegeEmployment: WelderROS:Positive: headache, visual changes, nauseaNegative: no fever, chills, chest pain, vomitingFor Examiner Only PHYSICAL EXAM Patient Name: Maureen TaroAge & Sex: 31 year old femaleGeneral Appearance: Alert, well-nourished, mildly obese woman. Appears uncomfortable, but non-toxic appearingVital Signs: HR 105 BP 178/98 RR 18 Pulse ox: 99% on RA T 37.4 (oral)Head: Normocephalic, atraumaticEyes: Normal, EOMI, PERRL, no blurring of optic discs if examinedEars: NormalMouth: NormalNeck: Normal, no thyromegalySkin: No rashes or bruisingChest: Bilateral breasts mildly tender to palpation, chest wall nontender.Lungs: CTAB, speaking in full sentences on room airHeart: Mildly tachycardic, rhythm regular, no M/R/GBack: Non-tenderAbdomen: Obese with stretch marks, soft, non-tender, + BSExtremities: ObeseRectal: Brown stool, guiac negativePelvic: External exam shows moderate vaginal bleeding with sutures in perineum. Patient declines internal exam. (if asked why, will say “because I just had the baby”).Neurological: GCS 15, CN II-XII grossly intact, normal strength and sensation in all four extremities. Reflexes 3+ throughoutMental Status: Normal mental status.For Examiner Only STIMULUS INVENTORY#1Emergency Admitting Form#2CBC#3BMP#4U/A#5Head CT#6Toxicology#7 LFTs and Coags#8Debriefing materialsFor Examiner Only LAB DATA & IMAGING RESULTSStimulus #2Stimulus #5Complete Blood Count (CBC)WBC11.3/mm3Diagnostic imagingHgb13.2 g/dLHead CT: negativeHct39%Platelets178/mm3DifferentialSegs75%Bands0%Lymphs 22%Monos 3%Eos 0%Stimulus #6Stimulus #3 ToxicologyBasic Metabolic Profile (BMP) SerumNa+ 132 mEq/LSalicylateNegK+ 3.7 mEq/LAcetaminophenNegCO2 24 mEq/LTricyclicsNegCl- 104 mEq/LETOH0 mg/dlGlucose 121 mg/dLBUN 28 mg/dLUrineCreatinine 1.2 mg/dLCocaineNegCannabinoidsNegPCPNegStimulus #4AmphetaminesNegUrinalysis (U/A)OpiatesNegColor yellowBarbituratesNegSp gravity 1.015BenzodiazepinesNegGlucose negProtein 3+Ketone negStimulus #7Leuk. Est. negLiver Function TestsNitrite negAST32 IU/LWBC 2ALT45 IU/L RBC 1Bili total 1.7 mg/dLBili direct 0.3 mg/dLAlbumin3.7 g/dLAlk Phos 34 IU/mLLearner Stimulus #1ABEM General HospitalEmergency Admitting FormName:Maureen TaroAge: 31 yearsSex: FemaleMethod of Transportation: Private carPerson giving information: PatientPresenting complaint: Headache, blurry visionBackground: The patient presents with her friend. They were shopping at a mall and the patient had onset of a severe headache and blurred vision that worsened over two hours and is now at a 6/10. She does not normally get headaches. Triage or Initial Vital Signs BP:178/98P:105R:18 and 99% on RAT :37.4 (oral)Learner Stimulus #2Complete Blood Count (CBC)WBC11.3/mm3Hgb13.2 g/dLHct39%Platelets178/mm3DifferentialSegs75%Bands0%Lymphs 22%Monos 3%Eos 0%Learner Stimulus #3 Basic Metabolic Profile (BMP) Na+ 132 mEq/LK+ 3.7 mEq/LCO2 24 mEq/LCl- 104 mEq/LGlucose 121 mg/dLBUN 28 mg/dLCreatinine 1.2 mg/dLLearner Stimulus #4 Urinalysis (U/A)Color yellowSp gravity 1.015Glucose negProtein 3+Ketone negLeuk. Est. negNitrite negWBC2RBC 1Learner Stimulus #5 Head CTLearner Stimulus #6 ToxicologySerumSalicylateNegAcetaminophen NegTricyclicsNegETOH0 mg/dlUrineCocaineNegCannabinoidsNegPCPNegAmphetaminesNegOpiatesNegBarbituratesNegBenzodiazepinesNeg Learner Stimulus #7 Liver function testsAST32 IU/LALT45 IU/L Bili total 1.7 mg/dLBili direct 0.3 mg/dLAlbumin 3.7 g/dLAlk Phos 34 IU/mLFor Examiner Date: Examiner: Examinee(s):Scoring: In accordance with the Standardized Direct Observational Tool (SDOT)The learner should be scored (based on level of training) for each item above with one of the following:NI = Needs ImprovementME = Meets ExpectationsAE = Above ExpectationsNA= Not Assessed Critical Actions NIMEAENACategoryCorrectly diagnosed patient with preeclampsiaPC, MKInitiated magnesium sulfate IVPC, MKTreated hypertensionPC, MK, PBLAdmitted patient to OB-GYN servicePC, MK, SBPThe score sheet may be used for a variety of learners. For example, in using the case for 4th year medical students, the key teaching points of the case may be the recognition of shock and treatment with appropriate fluid resuscitation. Other items may be marked N/A= not assessed.Category: One or more of the ACGME Core Competencies as defined in the SDOTPC= Patient CareCompassionate, appropriate, and effective for the treatment of health problems and the promotion of healthMK= Medical KnowledgeResidents are expected to formulate an appropriate differential diagnosis with special attention to life-threatening conditions, demonstrate the ability to utilize available medical resources effectively, and apply this knowledge to clinical decision makingPBL= Practice Based Learning & ImprovementInvolves investigation and evaluation of their own patient care, appraisal and assimilation of scientific evidence, and improvements in patient careICS= Interpersonal Communication SkillsResults in effective information exchange and teaming with patients, their families, and other health professionalsP=ProfessionalismManifested through a commitment to carrying out professional responsibilities, adherence to ethical principles, and sensitivity to a diverse patient populationSBP= Systems Based PracticeManifested by actions that demonstrate an awareness of and responsiveness to the larger context and system of health care and the ability to effectively call on system resources to provide care that is of optimal value Add 4-6 keywords for future searching functionsObstetrics and gynecology, hypertension, seizuresReferencesAugust P, Sibai B. Clinical features, diagnosis, and long-term prognosis of preeclampsia. In: UpToDate, Basow, DS (Ed), UpToDate, Waltham, MA, 2010.Norwitz ER, Repke JT. Management of preeclampsia. In: UpToDate, Basow, DS (Ed), UpToDate, Waltham, MA, 2010.Has this work been previously published?No.Debriefing Materials: 1. Review definitions of mild pre-eclampsia, severe preeclampsia, and eclampsiaMild preeclampsia SBP ≥ 140 mmHg and/or DBP ≥ 90 mmHgANDProteinuria of 0.3 grams or greater in a 24-hour urine specimen. (Note: blood pressure must be elevated in two measurements at least six hours apart.)Severe preeclampsiaNew onset proteinuric hypertension and at least one of the following:Symptoms of CNS dysfunction (blurred vision, severe headache, headache refractory to treatment, altered mental status)Symptoms of liver capsule distension (RUQ/epigastric pain, nausea, vomiting)Hepatocellular injury (AST and ALT ≥ twice normal)Severe blood pressure elevation (SBP ≥160 or DBP ≥110 on two separate occasions)Thrombocytopenia (<100,000 plt/mm3)Proteinuria (5 or more grams in 24 hours)Oliguria (<500 mL in 24 hours)Severe fetal growth restrictionPulmonary edema or cyanosisCerebrovascular accidentEclampsiaSeizure and/or coma in a patient with signs and symptoms of preeclampsia2. Review dosing and toxicity of magnesium sulfateThe mainstay of treatment in preeclampsia is magnesium sulfate IV. Magnesium sulfate therapy in preeclampsia decreases the risk of subsequent seizure by 50% (Magpie Trial).DosingMagnesium sulfate is given with a 4-6 gram IV bolus over 15-20 minutes followed by 2 gram/hour drip. In some countries, magnesium sulfate is given as 5 grams IM in each buttock (10 grams total) followed by 5 grams every four hours. These countries hate women. MetabolismMagnesium sulfate is excreted by the kidneys. If serum creatinine is 1.0 – 2.5 mg/dL, give the normal loading dose but consult with pharmacy and consider lowering the continuous rate to 1 gram/hour.If serum creatinine is >2.5 mg/dL, give the loading dose but no continuous dosing.ToxicityThe therapeutic range of magnesium sulfate is typically 4.8-8.4 mg/dL, however, in practice magnesium levels are not routinely checked and patients are managed symptomatically. The table below gives a rough guide of symptoms of magnesium sulfate overdose and the corresponding levels.SymptomMagnesium sulfate levelLoss of DTRs9.6-12.0 mg/dLRespiratory paralysis12.0-18.0 mg/dLCardiac arrest24-30 mg/dLThe treatment of magnesium sulfate toxicity is cessation of continuous drip and, in cases of cardiopulmonary compromise, giving 1 gram of calcium gluconate IV over 5-10 minutes.3. Review drugs recommended for treatment of hypertension in pre-eclampsiaDrug nameMechanism of ActionDosingNotesHydralazineDirect peripheral vasodilator10-50 mg po q6hr10-20 mg IM/IV q2hrIV, IM, PO.LabetololBeta blocker100-400 mg po bid20-80 mg IV q15 minIV or PO.Nifedipine(Adalat?, Procardia?)Calcium channel blocker30-60 mg extended release po daily, 10-20 mg po short-actingPO only. Is a tocolytic. Okay in patients with mild preeclampsia being monitored outpatient, but can cause ↓BP when used along with mag sulfate. ................
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