Clinical Note Pre-E on mag

Subjective: Pain well-controlled. Tolerating [clears], voiding [clear urine ]via Foley, not ambulating secondary to catheter. [Baby doing well in ][room.][NICU.] Patient [breast][formula]-feeding without issue.

Patient denies [headache][, vision changes][, RUQ/epigastric pain][, SOB][, nausea/vomiting][, somnolence][, flushing][, weakness or paralysis].

Objective: [Insert last documented vitals]

General: no acute distress

Pulmonary: clear to auscultation bilaterally

Cardiovascular: regular rate and rhythm, no clinically significant murmur

Abdomen: soft, non-tender

[Fundus: firm, non-tender, below the umbilicus]

Extremities: [no pedal edema][trace edema]

Neuro: alert & oriented x 3, DTRs [2+]

UOP over last [four] hours: [], [], [], [] Mg infusion rate: [] g/hr

[Insert mag levels: review --> labs --> chemistry --> right click relevant values --> return --> insert]

Assessment: []-year-old G[]P[] [in labor][s/p SVD][s/p LTCD] at [] []/7 wga on MgSO4 for seizure prophylaxis in setting of preeclampsia with severe features. Patient clinically stable[ on PPD][] without signs or symptoms of Mg toxicity or preeclampsia. Vital signs [stable], UOP [adequate].

[2]. [problem list]

[3]. [problem list]

[4]. [problem list]

[5]. [problem list]

Plan:

- Continue IV Mg prophylaxis until 24 hrs postpartum (end time []), with frequent assessments and Mg levels q6hrs

- Continue monitoring vital signs and treat persistently severe range BPs with IV anti-hypertensives

[- Transfer to postpartum floor after 24 hrs Mg prophylaxis]

- Pain control: [ibuprofen, ][acetaminophen, ][oxycodone prn]

- Diet: [clears][regular]

- Activity: bedrest with Foley

- Strict Is & Os with Foley

[- Routine postpartum care]