Gloria Smart: 55-Year-Old Female Presents To Your Office

Gloria Smart Is A 55 Year Old Female Who Presents To Your Office Today

Gloria Smart is a 55-year-old female presenting to the office for routine gynecologic care. Her medical history includes a cardiac stent placement at age 50, mild hypertension managed with lisinopril, and current medications Zocor (simvastatin) and Plavix (clopidogrel). Her surgical history is notable for tonsillectomy during childhood and bunion surgery. She maintains an active lifestyle, working full-time and exercising five days a week at the gym. Gloria is up to date with preventive screenings, including colonoscopies, mammography, and bone density testing, all within normal limits. Her BMI is 26 kg/m², indicating a healthy weight.

Her reproductive history reveals she experienced menarche at age 14 and menopause at age 52, with never having been pregnant. She has a current partner for two years, and they are preparing for marriage. Recently, Gloria and her fiancé discussed conception and decided to pursue fertility treatments, culminating in an IVF cycle utilizing donor eggs. She conceived on her second cycle and now presents at 12 weeks gestation for co-management, accompanied by concerns about elevated blood pressure and swelling.

Subjective Data (S)

Chief Complaint (CC): "My blood pressure has been high at home, and I have some swelling and rib pain."

History of Present Illness (HPI): Gloria reports that over the past week, she has noticed her blood pressure readings at home frequently exceeding 160/90 mm Hg, despite her usual mild hypertension. She reports persistent swelling in her face and bilateral legs, with pitting edema assessed as 2+ on inspection. The facial swelling has become more noticeable, especially in the morning. She also describes a dull right-sided rib pain that started after eating Chinese food, which she attributes to possible indigestion but is concerned it may be related to her current pregnancy. The pain is localized to the right upper abdomen, dull in character, and not associated with nausea or vomiting. She denies chest pain, shortness of breath, headache, vision changes, or overt visual disturbances. Gloria is worried about her appearance for her upcoming wedding in two weeks and inquires if she can be given something to reduce her swelling.

She reports no recent weight changes, no fever or chills, and no recent infections. Her activity level has remained consistent; she exercises regularly. Her social history includes never smoking or using recreational drugs, occasional wine consumption, and no tobacco use. She continues to work full-time, feeling that her activity helps her stay young. She and her fiancé have discussed having a child, which they are pursuing through fertility treatments. She is in a stable relationship and has never been pregnant.

Objective Data (O)

Vital signs measured during the visit show a blood pressure of 160/92 mm Hg, repeated measurements confirm readings around 160/88 mm Hg. Physical examination reveals 2+ pitting edema in both lower extremities and mild facial swelling. Her face appears slightly puffier than baseline, with no significant erythema or skin lesions. Cardiovascular exam shows regular rhythm with no murmurs. Lung auscultation is clear. Abdominal examination reveals mild tenderness in the right upper quadrant without guarding or rebound; no hepatomegaly or splenomegaly noted. No jugular venous distention or abnormal heart sounds. Neurological examination is unremarkable. Skin examination confirms facial edema and no rash or lesions. No hepatosplenomegaly or ascites are present.

Diagnostic Data

Laboratory and diagnostic results relevant to her current presentation include recent prenatal labs, which are within normal limits. Blood pressure readings suggest hypertensive control is inadequate. No recent urine protein measurements are available but would be essential for evaluating preeclampsia. Due to her pregnancy and swelling, suspicion for preeclampsia is high, warranting further testing such as urine protein-to-creatinine ratio and serum liver function panels. Ultrasound of the abdomen demonstrates no significant hepatomegaly or fluid collections. Fetal ultrasound confirms viable pregnancy at 12 weeks gestation with normal fetal morphology.

Assessment

1. Preeclampsia, early onset: The elevated blood pressure (160/88-92 mm Hg), facial and lower extremity edema, and recent pregnancy place her at risk for preeclampsia. The presence of edema, especially facial, in a pregnant woman at 12 weeks with escalating BP suggests preeclampsia, which must be confirmed with proteinuria and/or end-organ dysfunction evidence.
2. Hypertensive disorder of pregnancy: Uncontrolled mild hypertension in pregnancy can progress to preeclampsia or eclampsia. Monitoring and management are essential to prevent maternal and fetal complications.
3. Else, benign physiologic edema of pregnancy: Considered less likely given her BP and facial swelling severity; however, differential includes transient edema due to pregnancy hormonal changes.

Plan

Immediate management involves confirming preeclampsia diagnosis with urine analysis for proteinuria, serum liver enzymes, and platelet count. Initiate antihypertensive therapy tailored for pregnancy, such as labetalol or nifedipine, aiming to keep BP below 140/90 mm Hg. Hospital admission may be necessary if BP remains high or if signs of end-organ damage develop. Continuous fetal monitoring and serial ultrasounds are advised to assess fetal well-being.

Patient education emphasizes the importance of bed rest, avoiding salt intake, and prompt reporting of symptoms such as severe headache, visual changes, epigastric pain, or decreased fetal movement. She is advised to avoid any medications or herbal supplements without medical consultation.

Follow-up includes weekly blood pressure checks, repeat labs, and close collaboration with maternal-fetal medicine specialists. A multidisciplinary team approach is necessary to optimize maternal and fetal outcomes.

Reflecting on this case highlights the importance of early recognition and management of hypertensive disorders during pregnancy. This scenario underscores how preeclampsia can present subtly, with edema and mild BP elevations, yet progress rapidly to severe conditions affecting both mother and fetus. Recognizing risk factors, monitoring closely, and initiating timely intervention are key components of effective clinical care.

Health promotion strategies should focus on preconception counseling, managing chronic hypertension before pregnancy, and educating about the importance of routine prenatal visits. Socioeconomic and cultural factors can influence access to care, emphasizing the need for personalized patient education and support systems to improve outcomes in diverse populations.

References

• American College of Obstetricians and Gynecologists. (2019). Hypertension in Pregnancy. ACOG Practice Bulletin No. 222. Obstetrics & Gynecology, 133(1), e1-e25.
• Brown, M. A., et al. (2018). Hypertensive disorders of pregnancy: ISSHPClassification, diagnosis & management recommendations. Pregnancy Hypertension, 13, 119-125.
• Magee, L. A., et al. (2018). Diagnosis, Evaluation, and Management of Hypertensive Disorders of Pregnancy: Executive Summary. Obstetrics & Gynecology, 135(6), 1476-1487.
• Vink, J. P., et al. (2020). Obstetric Outcomes in Pregnant Women with Preeclampsia and Chronic Hypertension. Hypertension, 75(2), 514-521.
• Chong, Y. S., et al. (2019). The management of preeclampsia. Journal of Clinical Medicine, 8(10), 1675.