Is my HPI appropriate for a 17‑year‑old G1P0 (gravida 1, para 0) female at 33 weeks gestation after a restrained back‑seat motor vehicle collision, presenting with a severe throbbing headache and worsening low‑back pain, with tachycardia, tachypnea, normotension, normothermia, normal oxygen saturation, currently taking amoxicillin, ciprofloxacin‑dexamethasone otic suspension, and nitrofurantoin, and no prior surgical history?

HPI Evaluation for Pregnant Trauma Patient

Your HPI is incomplete and requires immediate additions to meet standard-of-care documentation for a pregnant trauma patient at 33 weeks gestation. Several critical elements are missing that directly impact clinical decision-making and risk stratification.

Critical Missing Elements

Maternal Assessment Gaps

Your HPI lacks essential trauma-specific details that predict maternal and fetal outcomes:

• Mechanism of injury specifics: You documented "another car going pretty fast hit the other vehicle in the front corner," but you need to document the estimated speed of both vehicles, whether airbags deployed, extent of vehicle damage, and whether the patient's vehicle was drivable after impact 1, 2.

• Loss of consciousness clarification: While you documented "denied losing consciousness," you need to explicitly document the Glasgow Coma Scale score on arrival, as this is a standard trauma assessment parameter 3.

• Seatbelt positioning detail is excellent: You correctly documented that the seatbelt was below the pregnancy belly and did not cross the chest—this is a critical detail for predicting uterine and placental injury 1, 2.

• Headache characterization is incomplete: You documented "throbbing headache" (8/10) that was "exacerbated by light" but improved. You must explicitly document whether this represents a "non-remitting headache," as this is a maternal early warning criterion in hypertensive disease of pregnancy 3. Given her tachycardia (pulse 104) and the head trauma mechanism, you need to rule out pre-eclampsia superimposed on trauma.

Fetal Assessment Gaps

Your HPI completely omits fetal-specific information that is mandatory for trauma in pregnancy:

• Fetal movement: No documentation of whether the patient reports normal fetal movement, decreased movement, or absence of movement since the accident 1, 2.

• Uterine contractions: You documented "no abdominal pain" but did not specifically ask about or document the presence/absence of uterine contractions or their frequency. Uterine contractions occur in 39.8% of pregnant trauma patients and are a key predictor of adverse outcomes 4.

• Uterine tenderness: You documented back pain but did not document whether there is uterine tenderness on palpation, which is an adverse factor requiring 24-hour admission 1.

• Amniotic fluid status: No documentation of whether membranes are intact or ruptured 1, 5.

Obstetric History Gaps

Your obstetric history is dangerously incomplete:

• Prenatal care documentation: You noted "no history of surgery" but did not document whether she has had prenatal care, how many visits, or when her last prenatal visit occurred. Lack of prenatal care is associated with increased risk of complications including genital tract lacerations 6.

• Current pregnancy complications: You listed current medications (amoxicillin, ciprofloxacin-dexamethasone otic, nitrofurantoin) but did not document why she is on these medications. Is the amoxicillin for a urinary tract infection? Is there a history of recurrent UTIs (explaining the nitrofurantoin)? This matters because urinary tract infections can cause preterm labor, which would change your differential for any contractions 7.

• Blood type and Rh status: Not documented. This is critical because all Rh-negative pregnant trauma patients require anti-D immunoglobulin 1, 2, 4.

Vital Signs Interpretation

Your vital signs require clinical interpretation in the context of pregnancy:

• Tachycardia (pulse 104) and tachypnea (RR 24): You documented these values but did not interpret them. In pregnancy, normal resting heart rate increases by 10-20 bpm and respiratory rate increases slightly, but a pulse of 104 with tachypnea of 24 after trauma warrants investigation for occult hemorrhage, pain, or anxiety 3, 1.

• Blood pressure "fluctuating between high and low": This is vague and clinically useless. You need to document specific values with timestamps. You documented one value (109/66 mmHg) but stated it fluctuated—document all values. A systolic BP >160 mmHg or diastolic BP >100 mmHg are maternal early warning criteria 3.

Recommended HPI Structure for Pregnant Trauma

Add these elements immediately:

Mechanism of Injury (expand current section)

• Estimated speed of both vehicles 1
• Airbag deployment status 1
• Vehicle damage severity 1
• Patient's position in vehicle (you have this—good)
• Seatbelt use and positioning (you have this—excellent) 1, 2

Maternal Symptoms (expand current section)

• Glasgow Coma Scale score 3
• Characterize headache as remitting vs. non-remitting 3
• Document visual changes specifically (you have "denies vision changes"—good)
• Document chest pain (you have this—good)
• Document shortness of breath (you have this—good)
• Add: Uterine contractions (frequency, duration, intensity) 1, 4
• Add: Uterine tenderness on palpation 1

Fetal Assessment (completely missing—add entire section)

• Fetal movement since trauma 1, 2
• Vaginal bleeding (you have "denies vaginal bleeding"—good) 1
• Amniotic fluid leakage 1, 5
• Document that fetal heart rate monitoring was initiated (if done) 1, 2

Obstetric History (expand current section)

• Prenatal care: number of visits, last visit date, any complications 6
• Blood type and Rh status 1, 2, 4
• Reason for current medications 7
• Previous pregnancy outcomes (you have G1P0—good, but document any prior losses)
• Estimated date of delivery (you have this—good) 3

Vital Signs (expand interpretation)

• Document all BP values with timestamps if "fluctuating" 3
• Interpret tachycardia and tachypnea in context of pregnancy and trauma 3, 1

Common Pitfalls You Avoided

You did well documenting:

• Seatbelt positioning (critical for predicting uterine injury) 1, 2
• Pertinent negatives (loss of consciousness, vision changes, chest pain, shortness of breath, abdominal pain, vaginal bleeding, numbness/tingling) 1
• Gestational age and EDD 3

Bottom Line

Your HPI captures the basic trauma narrative but fails to address pregnancy-specific risk factors and fetal assessment that are mandatory for a 33-week pregnant trauma patient. The most critical omissions are: (1) fetal movement and uterine contractions, (2) uterine tenderness, (3) Rh status, (4) prenatal care history, and (5) specific vital sign trends rather than "fluctuating" 1, 2, 4. Without these elements, your documentation does not meet the standard of care for trauma in pregnancy and could result in missed placental abruption, preterm labor, or Rh alloimmunization 1, 2.