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LM Soap Note

1. LM is a 32-year-old pregnant woman presenting with symptoms of hyperthyroidism including loose stools, sweating, fatigue, and chest pain. Lab tests confirm gestational hyperthyroidism. She also has chronic hypertension and gestational diabetes. 2. The patient will be treated for hyperthyroidism with methimazole, hypertension with increased labetalol, and diabetes with insulin. She will also receive lifestyle counseling and medication for gastroesophageal reflux. Regular monitoring of her thyroid, blood pressure, and blood sugars is recommended throughout pregnancy.

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Spreeha Choudhury
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2K views

LM Soap Note

1. LM is a 32-year-old pregnant woman presenting with symptoms of hyperthyroidism including loose stools, sweating, fatigue, and chest pain. Lab tests confirm gestational hyperthyroidism. She also has chronic hypertension and gestational diabetes. 2. The patient will be treated for hyperthyroidism with methimazole, hypertension with increased labetalol, and diabetes with insulin. She will also receive lifestyle counseling and medication for gastroesophageal reflux. Regular monitoring of her thyroid, blood pressure, and blood sugars is recommended throughout pregnancy.

Uploaded by

Spreeha Choudhury
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Download as DOCX, PDF, TXT or read online on Scribd
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SOAP Note

S:
LM is a 32 year old African-American female who presents to her
OB/GYN clinic at 14 weeks gestation
CC: Loose bowel movements 3x per day
Sweating profusely
Tired and hungry throughout day
Burning pain in chest after late-night eating
Difficulty sleeping at night
PMH: Hypertension
Spontaneous vaginal delivery of male infant at 37 weeks
gestation, 3 years ago
SH: ETOH (-)
Tobacco (+) occasional smoker
IVDA (-)
FH: Mother: Type II DM
Father: Type II DM, Hypertension
ROS: Exophthalmos
Aller: NKDA
O:

Medications:
Vitafusion Prenatal gummies, 2 gummies daily
Labetalol 100mg PO BID
PE:

T: N/A

Wt: 175lb

BP: 174/106
Pre-Pregnancy Wt: 160lb

P: 92

RR: 20
Ht: 54

Fetal Sonogram: Uterine size appropriate for gestational age


Vaccines: Up-to-date
Chem:

Na: 142

CBC: WBC: 9.0

Cl: 101
BUN: 19
K: 4.4
CO2: 27
SCr: 0.82 Glucose: 125
HgB: 11.2 Plt: 202
Hct: 34.1

Labs: TSI Antibody (+) FT4: 3.0ng/dL ()TSH:0.8mU/L


Urine Screen:
Glucose>1000mg/dL
50g OGTT: 149mg/dL
100g OGTT: 160mg/dL

A:
1. Hyperthyroidism/gestational transient thyrotoxicosis
a. In this patient, TSH levels are slightly low, TSI antibody is
positive and free T4 level is increased indicating possible
gestational transient thyrotoxicosis. Gestational transient
thyrotoxicosis is also common at the end of the first
trimester.
b. Hyperthyroidism can manifest as many types of symptoms
including: increased bowel movements, increased
perspiration and heat intolerance, increased appetite,
insomnia, exophthalmos.
c. Hyperthyroidism in pregnancy can lead to spontaneous
abortion, premature labor, pre-eclampsia and other
complications.
d. Goals of therapy: Maintain clinical euthyroidism to
decrease symptoms with least risk to fetus
e. Treatment: During first trimester, propylthiouracil is the
drug of choice. For first and second trimester, methimazole
should be used. Propranolol can be used for short term
symptom management.
2. Chronic pre-existing hypertension
a. Defined as blood pressure greater than 140/90mmHg that
existed before pregnancy, before the 20th week of
pregnancy or persists after 12 weeks after birth. Severe
hypertension is greater than 160/110. This patient has a BP
of 174/106 and past medical history of hypertension being
treated with labetalol.
b. Hypertension during pregnancy can lead to maternal
morbidity, superimposed preeclampsia, low birth weight,
and perinatal death.
c. Goals of therapy: Reduce BP to 120-140/80-90 to reduce
risk of cardiovascular and cerebrovascular events
d. Treatment: If BP > 160/110, antihypertensive medications
are recommended. Drug of choice is methyldopa or
labeltalol. Nifedipine can be added as a second or third line
treatment.
3. Gestational Diabetes Mellitus:
a. Two stop glucose challenge test is necessary to diagnose
GDM. The 50-gram glucose test is elevated above 130

mg/dL and the 100g OGTT exceeds 145mg/dL.


Pharmacologic therapy is recommended for this patient
because she cannot maintain normoglycemia despite
trying various diets and nutritional therapy.
b. Treatment: Insulin should be started at 0.2 units per kg of
the current pregnancy weight, divided
4. Gastroesophageal reflux:
a. Symptoms, such as a burning in the chest after eating,
increases from first trimester to third trimester. Pregnancy
lowers esophageal sphincter tone, which will return to
normal postpartum. Reflux may lead to aspiration of gastric
contents which may lead to further complications.
b. Goals of therapy:
c. Treatment: First line therapy is lifestyle and diet changes. If
patient has persistant symptoms they can start sucralfate.
If the reflux continues, H2RA and PPI can be used.
P:
1. Hyperthyroidism:
a. Methimazole 5mg TID in relation to meals
b. Monitoring: Thyroid function (TSH, T3, T4) should be tested
every 2 weeks and then every 4-6 weeks after
euthyroidism is achieved
c. If patient can no longer tolerate methimazole,
thyroidectomy is second line
2. Hypertension:
a. Increase labetalol dose to 200mg BID and monitor blood
pressure. Labetalol can be increased to 2400mg/day if
necessary
b. Counsel patient on smoking cessation
3. Gestational Diabetes Mellitus:
a. Start insulin glargine at 10 units every morning and and
insulin lispro 5 units before the largest meal.
b. Monitor blood sugar 4 times per day and record in log to
bring to the next visit.
4. GERD:

a. Counsel patient on lifestyle and diet changes. For example,


no eating directly before bed, avoid caffeine, spicy foods,
etc.
b. If reflux continues, start sucralfate 1 g four times daily for
4-8 weeks.

References:
1. Nordyke RA, Gilbert FI Jr, Harada AS. Graves' disease. Influence of age on
clinical findings. Arch Intern Med 1988; 148:626.
2. Trzepacz PT, Klein I, Roberts M, et al. Graves' disease: an analysis of thyroid
hormone levels and hyperthyroid signs and symptoms. Am J Med 1989; 87:558.
3. Luewan S, Chakkabut P, Tongsong T. Outcomes of pregnancy
complicated with hyperthyroidism: a cohort study. Arch Gynecol
Obstet 2011; 283:243.
4. Glinoer D, de Nayer P, Bourdoux P, et al. Regulation of maternal
thyroid during pregnancy. J Clin Endocrinol Metab 1990; 71:276.
5. Melmed S, Polonsky KS, Larsen PR, et al: Williams textbook of Endocrinology.
12th edition. Elsevier Saunders Company, 2011, pp 348-414
6. Stagnaro-Green A, Abalovich M, Alexander E et al. Guidelines of the American
Thyroid Association for the diagnosis and management of thyroid disease during
pregnancy and postpartum. Thyroid 21(10), 10811125 (2011).
7. American College of Obstetricians and Gynecologists, Task Force on
Hypertension in Pregnancy. Hypertension in pregnancy. Report of the American
College of Obstetricians and Gynecologists Task Force on Hypertension in
Pregnancy. Obstet Gynecol 2013; 122:1122.
8. Sibai BM. Chronic hypertension in pregnancy. Obstet Gynecol 2002; 100:369.
9. VanDorsten JP, Dodson WC, Espeland MA, et al. National Institutes of Health
Consensus Development Conference Statement: Diagnosing Gestational Diabetes
Mellitus. NIH Consens State Sci Statements 2013; 29:1.

10. Nicholson WK, Wilson LM, Witkop CT, et al. Therapeutic management, delivery,
and postpartum risk assessment and screening in gestational diabetes. Evid Rep
Technol Assess (Full Rep) 2008; :1.
11. Witter FR, King TM, Blake DA. The effects of chronic gastrointestinal
medication on the fetus and neonate. Obstet Gynecol 1981; 58:79S.
12. Physician's Desk Reference, 46th ed, Physician's Desk Reference, Oradell, NJ
1992.
13.
Ranchet G, Gangemi O, Petrone M. Sucralfate in the treatment of gravidic
pyrosis. Giornia Italiano de Ostericia Ginecologia 1990; 12:1.

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