Transcribed Medical Transcription Sample Reports and Examples
Transcribed Medical Transcription Sample Reports and Examples
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Sample Type / Medical Specialty: Obstetrics / Gynecology
Sample Name: Pre-Eclampsia & Eclampsia

Description: A sample note on pre-eclampsia & eclampsia.
(Medical Transcription Sample Report)

PRE-ECLAMPSIA is a very serious condition unique to pregnancy in which blood pressure, the kidneys and the central nervous system are compromised. It usually occurs from the 20th week of pregnancy to 7 days postpartum. The cause is unknown. It is also known as pregnancy-induced hypertension or toxemia of pregnancy.

ECLAMPSIA is the end-stage of the pre-eclampsia process. The vast majority of women who develop pre-eclampsia are pregnant with their first child and are towards the end of their child-bearing years. There are identifiable risk factors for developing pre-eclampsia: family history of pre-eclampsia, previous pregnancy with pre-eclampsia, multiple gestation, and a hydatiform mole (an intrauterine growth that mimics pregnancy). A chronic high blood pressure and underlying blood vessel disease increases the risk. Pre-eclampsia ranges from mild to severe to eclampsia as the end-stage. Untreated pre-eclampsia can result in a stroke, fluid-build up around the lungs, kidney failure, death of baby and death of mother.

SIGNS AND SYMPTOMS:

MILD PRE-ECLAMPSIA:
* Significant blood pressure increase even if you are still within the normal blood pressure limits.
* Swelling in the face, hands and feet which worsens in the a.m.
* Gaining more than a pound a week, especially in the last trimester.
* Routine prenatal checkup reveals protein in the urine.
* Seizures are possible.

SEVERE PRE-ECLAMPSIA:
* More blood pressure increase.
* Further swelling in face, hands and feet.
* Visual disturbances.
* Headache.
* Irritability.
* Abdominal pain.
* Tiredness.
* Decreased urination.
* Seizures possible.
* Nausea and vomiting.

ECLAMPSIA:
* Symptoms worsen.
* Seizures.
* Muscle twitches.
* Coma.

TREATMENT:
* Diagnosis - blood tests, urinalysis, blood pressure monitoring.
* Mild preeclampsia can be treated at home. Severe symptoms require hospitalization and possible early delivery of the baby, often by cesarean section.
* Daily weighing.
* Daily monitoring for protein in urine.
* Medications to lower blood pressure if preeclampsia is severe.
* Magnesium sulfate or other anti-seizure drugs may be necessary to prevent seizures.
* Get lots of rest! Lay on your left side to help circulation.
* Follow any dietary advice given by your doctor.
* Get regular prenatal checkups! Eat a nutritious diet and take your vitamin supplements.
* Never take any medications that are not prescribed or recommended by your physician.
* Call the office if your headaches become severe, you have visual disturbances or if you gain more than 3 pounds in 24 hours.

RESTRICTING CAFFEINE:
You should reduce your intake of caffeine by cutting back on coffee and other caffeinated beverages like soda. In addition, you should avoid chocolate that also contains caffeine.

RESTRICTING SALT:
You are to restrict your salt intake by reducing or eliminating table salt from your meals and avoiding foods that are high in salt concentration. For more information about which foods are high in salt, read the label of any foods you intend to consume and look for sodium content.

Keywords: obstetrics / gynecology, central nervous system, intrauterine growth, pre eclampsia, blood pressure, pregnancy, preeclampsia, eclampsia,
NOTE: These transcribed medical transcription sample reports and examples are provided by various users and are for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports. These transcribed medical transcription sample reports may include some uncommon or unusual formats; this would be due to the preference of the dictating physician. All names and dates have been changed (or removed) to keep confidentiality. Any resemblance of any type of name or date or place or anything else to real world is purely incidental.
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Transcribed Medical Transcription Sample Reports and Examples