Case Study for Patient Complaining Of Double Vision And A Throbbing Headache

Objective
For this activity, you will demonstrate your ability to utilize SBAR from your role in your professional work setting.

Think of a situation where SBAR communication would be important. Use Kaltura to record your SBAR delivery. Post your SBAR example in the discussion forum to share with your peers. After posting your SBAR delivery, you will post a response to two peers with constructive feedback on their SBAR delivery.

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Helpful outline of SBAR:

Situation: What is happening?
Background: What is the background?
Assessment: What do you find and what do you think the problem is?
Recommendation: What would I recommend? Case Study for Patient Complaining Of Double Vision And A Throbbing Headache

SBAR Communication

Situation: A 32-year-old African American female patient, G1P0 at 35 weeks gestation, presents to the emergency department with complaints of double vision and a throbbing headache since morning.

Background: The patient, at twenty weeks gestation, developed preeclampsia and has been taking methyldopa 500 mg PO daily to help control her blood pressure. She reports that the headache and double vision began in the morning and had been getting worse and responding to analgesic use. There are no associated symptoms such as epigastric pain, shortness of breath, or seizures. She denies any hotness of body, changes in her urine output or color, and reports no prior hospital admission or surgeries.

Assessment: On examination, she is well-kempt and dressed appropriately for the season and weather. The patient is not in obvious respiratory distress but appears anxious about her symptoms. She has no palmar or conjunctival pallor, scleral jaundice, moist mucus membranes, capillary refill time of less than 2 seconds, and anasarca (generalized body edema). Her vital signs are as follows: BP 170/112 mmHg, HR 78 bpm, RR 20 bpm, Temp. 37.6 ⁰C, and Spa02 at 96% on Room air. All other cranial nerves are intact, she has a soft neck and kerning, and Brudzinski’s signs are negative, normal bulk, tone, and power in all limbs, and her deep tendon reflexes are 3+. Her lungs are clear bilaterally with good air entry and vesicular breath sounds. Her heart sounds S1S2 heard without murmurs. She has pitting edema grade +2 to the sacral level. Her abdomen is non-distended, soft, and non-tender, with no mass or hepatosplenomegaly, tympanic percussion note in all quadrants, and present bowel sounds. Based on the findings of blurred vision, headache, elevated blood pressure, and anasarca in a G1P0 at 35 weeks gestation, the patient is likely experiencing preeclampsia with severe features. Case Study for Patient Complaining Of Double Vision And A Throbbing Headache

Recommendation:

1. Laboratory testing: Blood drawn for complete blood count, renal function tests, and liver function tests will help to assess for the development of complications from the disease, such as hemolysis, elevated liver enzymes, and low platelets (HELLP) syndrome, and renal insufficiency (Barda et al., 2023). The patient requires a urinalysis to check for proteinuria to help reinforce the primary diagnosis.
2. Treatment: Administer magnesium sulfate 5mg IM to each buttock to help with seizure prophylaxis in the patient. Stop methyldopa and administer hydralazine 5mg IV STAT dose, and then 5mg IV every fifteen minutes PRN to reduce the patient’s blood pressure. Administer betamethasone-acetate 0.125 mg/kg single dose to stimulate fetal lung maturity in anticipation of delivery. A single dose of betamethasone-acetate 0.125mg/kg is equally as effective as the standard of care dosage of two IM injections of 0.25mg/kg of betamethasone-acetate plus betamethasone-phosphate combination regimen (Schmidt et al., 2018). Also, a single dose of betamethasone-acetate 0.125mg/kg results in lower fetal and maternal exposures to betamethasone, which reduces the incidences of adverse effects of the medication (Schmidt et al., 2018)Case Study for Patient Complaining Of Double Vision And A Throbbing Headache . Finally, I recommend that the patient be prepared for delivery 48 hours after the dose of betamethasone is administered.
3. Supportive management: The patient should be admitted to the prenatal ward on the obstetrics and gynecology floor. The patient’s vital signs, blood pressure, and heart rate should be monitored every fifteen minutes. Continuous external fetal heart rate monitoring for any late decelerations that would indicate fetal distress should be instituted for the patient. The patient should receive health education regarding her presentation to allay her anxiety and prepare her for post-partum care for her and the newborn. A repeat urinalysis should be scheduled for this patient in the morning. Also, she should be encouraged to take short walks, do active leg exercises, or do movements to reduce the chances of developing deep vein thrombosis.

Conclusion

An obstetrics and gynecology resident saw the patient and recommended admission into the prenatal ward on the obstetrics and gynecology floor. The patient had samples collected for complete blood count, renal function test, and liver function test. Her urinalysis in the emergency department was positive for proteinuria 3+, and her blood pressure after hydralazine 5mg IV every 15 minutes for the first hour of admission was 148/98 mmHg. The patient received magnesium sulphate and betamethasone as per the prescriber’s order and is on close monitoring with expected delivery in two days times through induction and vaginal birth.

References

Barda, S., Yoeli, Y., Stav, N., Naeh, A., Maor-Sagie, E., Hallak, M., & Gabbay-Benziv, R. (2023). Factors associated with progression to preeclampsia with severe features in pregnancies complicated by mild hypertensive disorders. Journal of Clinical Medicine, 12(22), 7022. https://doi.org/10.3390/jcm12227022

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Schmidt, F. A., Kemp, W. M., Rittenschober-Bohm, J., Kannan, S. P., Usuda, H., Saito, M., Furfaro, L., Watanabe, S., Stock, S., Kramer, W. B., Newnham, P. J., Kallapur, G. S., & Jobe, H. A. (2018). Low-dose betamethasone-acetate for fetal lung maturation in preterm sheep. American Journal of Obstetrics and Gynecology, 218(1), 132.e1-132.e9. https://doi.org/10.1016/j.ajog.2017.11.560 Case Study for Patient Complaining Of Double Vision And A Throbbing Headache