Date: [DATE]
Patient: [Patient Name]
MRN: [Medical Record Number]
Gravida [G] Para [P] [Number of Pregnancies] [Number of Deliveries at >20 Weeks] [Number of Abortions]
Diagnosis: Eclampsia
Reason for Visit: Admission for management of eclampsia.
History of Present Illness:
Document the date and time of seizure onset.
Describe the characteristics of the seizure(s) (witnessed by healthcare provider or reported by patient/family).
Inquire about any prodromal symptoms (headache, visual disturbances, epigastric pain) prior to seizure onset.
Review prenatal care history, including blood pressure readings and proteinuria results.
Past Medical History:
Briefly document any relevant past medical conditions, surgeries, or allergies, especially chronic hypertension or preeclampsia.
Social History:
Document smoking, alcohol, and illicit drug use (past and present).
Family History:
Inquire about a family history of hypertension or preeclampsia.
Medications:
List all current medications, including prenatal vitamins.
Allergies:
Document any known allergies.
Physical Exam:
Vital Signs: Include blood pressure, heart rate, respiratory rate, oxygen saturation (SpO2), and temperature.
General: Assess for appearance of illness (e.g., lethargy, confusion).
Neurologic: Assess mental status for confusion, lethargy, or focal neurological deficits.
Funduscopic exam: Assess for papilledema (swollen optic nerve) indicating increased intracranial pressure.
Pulmonary: Auscultate for rales (crackling sounds) indicating pulmonary edema (fluid buildup in the lungs).
Cardiovascular: Assess for signs of heart failure (e.g., jugular venous distention, peripheral edema).
Abdominal: Assess for tenderness or epigastric pain.
Laboratory:
Document any laboratory tests performed, such as:
Complete blood count (CBC) to assess for anemia or thrombocytopenia (low platelet count).
Electrolytes: May show abnormalities due to dehydration and electrolyte imbalances.
Liver function tests (LFTs): May show elevations indicating liver injury.
Renal function tests (RFTs): May show elevated creatinine indicating kidney dysfunction.
Coagulation studies: May show abnormalities indicating bleeding risk.
Urine dipstick: To assess for proteinuria (presence of protein in the urine).
Imaging:
Imaging studies are not diagnostic for eclampsia but may be performed to rule out other causes of seizures or assess for fetal well-being (e.g., non-stress test, biophysical profile).
Assessment:
Eclampsia confirmed based on the presence of generalized tonic-clonic seizures in the setting of preeclampsia (gestational hypertension and proteinuria).
Assess the severity of preeclampsia (mild, severe, eclampsia).
Consider differential diagnoses for seizures in pregnancy (e.g., primary epilepsy, eclampsia mimickers).
Plan:
Delivery:
The primary goal of treatment is immediate delivery of the fetus.
The mode of delivery (vaginal or cesarean section) will depend on various factors, including gestational age, fetal well-being, and maternal condition.
Anticonvulsant Therapy:
Administer intravenous magnesium sulfate as the first-line medication to control seizures and prevent further episodes.
Consider alternative anticonvulsants if magnesium sulfate is contraindicated or ineffective.
Blood Pressure Control:
Administer medications to lower blood pressure gradually, aiming for a controlled but not overly aggressive reduction.
Supportive Care:
Monitor vital signs and fetal well-being closely.
Maintain adequate hydration with intravenous fluids.
Monitor for complications (e.g., HELLP syndrome, disseminated intravascular coagulation [DIC]).
Follow-up:
Continue close monitoring of maternal and fetal well-being after delivery.
Gradually wean off anticonvulsant medications once seizures are controlled.
Monitor blood pressure and manage any underlying chronic conditions.
Provide counseling and support to the patient and family regarding the complications of eclampsia and future pregnancy risks.
Note: This is a template and should be adapted to the specific patient encounter. Document all relevant details regarding seizure characteristics, prodromal symptoms, prenatal care history, physical exam findings, laboratory