Patient: [Patient Name] MRN: [Medical Record Number] Date: [Date of Visit]
主诉 (zhǔ訴) Chief Complaint: This section may be blank or contain nonspecific complaints depending on the severity of hypertension.
Headache (especially frontal)
Visual disturbances (blurred vision, flashing lights) – concerning symptom
Dizziness
Epigastric pain (upper abdominal pain) – concerning symptom
现病史 (xiàn bìng shǐ) History of Present Illness:
Gestational age (weeks)
Onset and duration of symptoms
Highest recorded blood pressure readings
Presence of symptoms (see Chief Complaint) and their association with blood pressure readings
Recent changes in lifestyle (diet, weight gain)
Fetal movement (frequency, any changes)
既往史 (jì wàng shǐ) Past Medical History:
Underlying medical conditions that can contribute to hypertension (chronic kidney disease, pre-existing hypertension)
Prior pregnancies (history of preeclampsia or gestational hypertension)
Prior surgeries or procedures
History of other cardiovascular diseases
家族史 (jiā zú shǐ) Family History:
Family history of hypertension or cardiovascular disease (important risk factor)
社会史 (shè huì shǐ) Social History:
Smoking history (significant risk factor)
Alcohol intake (excessive intake can worsen hypertension)
Diet (high sodium intake can worsen hypertension)
Pre-pregnancy weight and weight gain during pregnancy
查体 (chá tǐ) Physical Examination:
Vital signs (blood pressure in both arms, heart rate)
General appearance (signs of preeclampsia – facial puffiness, edema)
Fundoscopic exam (examination of the eye for signs of hypertensive retinopathy)
Abdominal exam (fetal palpation, fundal height assessment)
Deep tendon reflexes (hyperreflexia can be a sign of preeclampsia)
辅助检查 (fú zhu zhuān chá) Laboratory Tests:
Electrolytes (potassium, sodium) – to assess electrolyte balance
Creatinine and BUN – to assess kidney function
Urinalysis – to assess for proteinuria (a sign of preeclampsia)
Complete blood count (CBC) – to assess for preeclampsia
Liver function tests – to assess for preeclampsia
胎儿监测 (tāi ér jiān cé) Fetal Monitoring:
Non-stress test (NST) or biophysical profile (BPP) – to assess fetal well-being
影像学检查 (yǐng xiàng xué jiǎn chá) Imaging Studies:
Doppler ultrasound – may be used to assess blood flow in the uterine arteries and umbilical cord
诊断 (zhěn duàn) Diagnosis:
Gestational age (weeks)
Type of hypertension in pregnancy (gestational hypertension, chronic hypertension with superimposed preeclampsia, preeclampsia)
Severity of hypertension (based on blood pressure readings)
Presence of preeclampsia symptoms or complications (proteinuria, abnormal fetal testing, evidence of end-organ damage)
治疗方案 (zhì liáo fāng àn) Treatment Plan:
Lifestyle modifications (bed rest if needed, dietary changes)
Medications (antihypertensive medications if indicated)
Fetal monitoring frequency (based on severity)
Delivery plan (consideration of timing and mode of delivery based on maternal and fetal health)
预后 (yù hòu) Prognosis:
Discuss the outlook based on the type and severity of hypertension, response to treatment, and fetal well-being.
Early diagnosis, close monitoring, and timely intervention are crucial to prevent complications for both mother and baby.
健康指导 (jiàn kāng zhǐ dào) Patient Education:
Importance of following the prescribed treatment plan (medication, rest)
Importance of regular prenatal visits and monitoring
Warning signs of worsening preeclampsia (severe headache, visual changes, right upper quadrant pain, decreased fetal movement)
Importance of a healthy diet and weight management during pregnancy
下次随访 (xià cì suí fǎng) Next Follow-up:
Schedule for the next appointment depends on the severity of hypertension and the delivery plan.
Close monitoring of blood pressure, fetal well-being, and potential complications is essential.