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  • 8/3/2019 Case Pres Output

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    Name:

    ADMITTING HISTORY:

    22 hours PTA (January 2, 2012, 2 am)

    patient experienced diffuse headache

    grade 8/10 lasting for 3 hours spontaneously relieved, not

    accompanied by blurring of vision, nausea and vomiting,

    chest and abdominal pain,. No consult was done, no

    medication has taken.

    14 hours PTA (8am), BP was noted to be elevated at

    160/100, however no headache and blurring of vision noted.

    3 hours after, patient took 1 tab of Methyldopa 200mg/tab.

    There was a good fetal movement.

    5 hours PTA (7pm), BP was elevated at 180/100,

    however asymptomatic, patient took sublingual nifedepine 5

    mg/tab.

    2 hours PTA (10PM), BP was rechecked and 170/

    100, still asymptomatic, patient took 1 tab methyl dopa

    250mg/tab. Bp was checked after 30 mins and still elevated

    at 170/100. Patient decided to seek consult and was

    subsequently admitted.

    Patient denies any hospitalization, surgery, and

    illness during her childhood days.

    In 2008, patient was diagnosed with Systemic lupus

    erythematosus(SLE). Initially she had malar rash, hair loss,intermittent fever and joint pains. Currently maintained on

    calcium carbonate, prednisone 30mg OD, and

    hydrochloroquine 200mg/tab OD. That year, she also had

    Diabetes Mellitus type II. She was previously maintained on

    Metformin 500 mg/tab since 2008 and discontinued on 5

    mos. AOG; currently maintained on Insulin humulin N

    prebreakfast,- 18 u, predinner- 10u, Humalogpremeal- 8u on daily CBG monitoring. Usual pre-meal

    77mg/dl, lowest premeal- -60mg/dl, highest premeal

    148mg/dl; no post meal cbg monitoring. Also during 2008,

    She had Autoimmune Hemolytic Anemia but was resolved

    last December 2011. She had six blood transfusion, 3x during

    2008, 2x during June 2011, and 1x last November 2011.

    Patient was diagnosed with CHVD with

    superimposed pre-eclampsia last December 2011. Her usual

    BP is 120/80, highest BP is 180/100 currently on Methyldopa

    250mg/tab 1 tab twice a day and Nifedipine 5mg/1 tab twice

    a day. She also has probable hyperthyroidism. She had an

    operation for molloscum contagiosum last December. She

    was also positive with trichomoniasis.

    Patient doesnt have any allergic reactions. She did

    not complete her immunizations. According to her, her father

    had DM II and Hypertension. Her paternal aunt, grandmother

    and cousin have hyperthyroidism.

    Patients had her first menstruation when she was 13

    years old with the interval of 28-30 days and 4-5 days

    duration. She consumed 2 pads per day, fully soaked. She

    denies dysmenorrhea. Her last menstrual period was on June

    1-5, 2011. She had her first sexual intercourse when she was

    18 years old. She had three sexual partners and denies

    dyspnareunia and positional bleeding.

    Patient delivered her first baby from her first partner

    in August 1997. The baby was preterm (32wks AOG), male, by

    NSD. The delivery was attended by a midwife. Last year

    (2011) she had her second pregnancy from her third partner

    DEMOGRAPHIC DATA:

    Name: P.G., 33 y/o

    Date of Birth: July 13, 1978Address: 75 Apple St., Paranaque City

    Occupation: Telemarketer

    Nationality: Filipino

    CivilStatus: Married

    Religion: Roman Catholic

    Date of Admission: January 3, 2012

    Informant: Patient

    Reliability: Good

    Chief Complaint: Elevated blood pressure

    Final Diagnosis: G2P2 (0202) Pregnancy uterine 32-33 wks

    ROP delivered via classical cesarean section to alive baby boy BW 1.36kg DL:39cm AS:5,8ga super

    imposed pre-eclampsia; SLE in flare (nephritis,

    anemia); pre gestational diabetes, on insulin; to

    consider hyperthryroidism; mixed vaginal

    infection, on treatment; molluscum contagiosum.

    UNIVERSITY OF SANTO TOMAS

    College ofNursing

    Obstetric Nursing Case Presentation

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    and gave birth last January 6, 2012 by CS. She and her

    partner use withdrawal family planning method.

    Prenatal Checkups

    1st

    PNCU at private OB-Gyn in Muntinlupa at 5 mos.

    AOG. She had urinalysis and found out that was nonreactive

    with HbsAG but she was positive with Urinary tract infection.

    She was given unrecalled antibiotics for 7 days.

    2nd

    PNCU at private OB in Paranaque: Congenital

    anomaly requested but done only at 8 mos AOG (December

    3, 2011).

    - Single, live, intrauterine pregnancy in breechpresentation 27 3/7 wks by composite aging

    with good somatic and cardiac activities.- Normohydramnios- Plancenta anterior, high lying, grade 2- SEFW is appropriate for 27 3/7 weeks- Fetal anomaly scan shows no gross abnormality

    at the tme of scan

    - - UTZ EDD:2/29/12- (+)MV, FeSO4 BID, Folic acid

    3rd

    PNCY UST OB 1st

    PNCU with a BP of 160/100

    - CBC (12/16): Hgb 9.0, hct 0.29, WBC 11.1, pltadeq, N91 L08 M01 (done outside)

    - UA (12/16): Yellow, sl. Hazy, 1.010 (-)glucose;(+2)albumin, WBC 8-15 mpf, RBC 0-2/hpf,

    - December 17 patient was admitted- BUA 9.30 (inc). Crea 1.18, SGOT 17.94, SGPT

    18.16, LDH 200.4 (nc), Na 138.0 , K 4.22,

    iPO4 4.51, iCa 1.30

    - 24 hour urine protein-1.29g/24hr; C3-0.51(low)

    - BPS WITH Copplet velocimetry (12/18)-Single live intrauterine pregnancy about28-29 weeks in breech presentation

    -Anteriorly located plancenta grade II-BPS 8/8, SEFW=1051 weeks-Normal umbilical artery Doppler inides.

    - CBC (12/18) Hgb 94, Hct 0.27. WBC 11.1, Plt22.5, N74 L26

    - CBC (12/22) Hgb 95, Hct 0.27, Plt 22.5, N74L28.

    Patient was born in Nueva Ecija. Her family moved to

    Paranaque when she was 2 years old because her dad found

    a job there. She described their house as a bungalow type

    with a maid and away from pollution. They are seven people

    there. They have a maid so she didnt do household chores.

    She studied at San Roque Catholic School from elementary

    until fourth year high school. In college, she took up

    management at Lyceum University, Intramuros Manila and

    graduated in 1998. She worked as a clerk from 2000- 2002

    and became a telemarketer in Equitable PCI bank in Makati

    since 2002. According to the patient, her salary is just enough

    to raise a family. She had her first partner back in college.

    They lived in together for three years and had a baby boy.

    Their relationship didnt work out. They broke up. After 2

    years she met another guy but like her first relationship, it

    didnt work out. After three years, she met another man she

    got pregnant. They married in June 25, 2011.

    The patient is a previous smoker from 1994 2007

    1.3 pack years) and occasional light alcoholic beverage

    drinker. She denies illicit drug use.

    Patient didnt involve in any recreational activities

    and regular exercises. She just walks and commutes everyday

    and she claims that it is her only exercise. Her sleep pattern is

    normal without any interruptions. She sleeps 7 hours and

    feels fully rested when she awakes. Shes not fond of eating

    vegetables. She eats fried foods every breakfast and dinner at

    home and she during lunch, she just buy food to fast-food

    chains around their building.

    Patient claims that she doesnt have a strong

    support system. Since she had 2 partners before the one that

    she got married, there are some problems with the

    relationship of her husband and her first child. She lacks

    financial support from the father of her first child. Since 2005,

    she didnt have a communication with her him. Patients

    support comes from her mother whos with her all

    throughout her pregnancy and her hospitalizations.

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    REVIEW OF SYSTEMS

    On Admission: On Interview:

    BP: 180/100

    PR: 90

    RR: 19

    Temperature: 36.9oC

    Height: 153cm; Weight: 50.9

    General Survey: Conscious, coherent, ambulatory,

    dehydrated, not in cardiorespiratory distress

    Skin: warm, dry skin, no active dermatoses

    HEENT: Pink Palpebral conjuntivae, anicteric sclerae,

    pupils 2-3 mm. septum midline, turbinates not

    congested, no nasoaural discharge, no tragal

    tenderness, moist buccal mucosa, no oral and palatal

    ulcers, tonsils not enlarged.

    Neck: no limitation in motion, no palpable cervical

    lymph node, thyroid gland diffusely enlarged, no

    palpable masses.

    Respiratory: Symmetrical chest expansion, equal tactile

    fremitus , no retractions, clear breath sounds

    Cardiovascular: adynamic precordium AB at 5th

    LICS

    MCL regular rate and rhythm with no heart murmurs

    Abdomen: globular, FHT 140, no uterine contractions,

    ExternalGenitalia: (=5) fresh colored rounded papules

    with central umbilication over the medial aspect of both

    upper thigh measuring 0.5cm -1 cm (4 on right, 1 on

    left)

    SE: Cervix pink with whitish to yellowish curd like foul

    smelling discharge

    IE: Cervix soft, long and closed

    NeurologicExam: Conscious coherent oriented to

    person place and time, can follow commands

    Cranialnerves: intact cranial nerves

    Motor: no weakness, MMT 5/5 on all extremities

    Sensory: No sensory deficits

    Reflexes: superficial, deep tendon normal.

    General/ Constitutional: Appears tired and sleepy and can only be interviewed for a

    few minutes because of this. Ambulatory but needs assistance.

    Skin: Denies rash or itching. Skin is warm to touch and slightly dry. Bluish-purplish

    discoloration, approximately 5 cm on the left antecubital area, tender to touch. Evenly

    colored skin.

    HEENT: Denies blurring of vision and headache.

    Unremarkable nose discharge, cough or dental difficulties. No difficulties with

    hearing. Can move tongue in all directions. No neck stiffness, able to rotate head w/o

    pain/difficulty. No tenderness, pain and masses noted in throat area.

    Cardiovascular: Negative for heart murmurs, palpitations, chest pain. Has a BP of

    140/90, PR of 78.

    Respiratory: Denies shortness of breath and chest pain.

    Negative for colds, cough and dyspnea.

    Clear breath sounds upon auscultation.

    Symmetrical chest expansion.

    Gastrointestinal: reports acute abdominal pain due to surgery done, pain score of

    5/10. Denies nausea and vomiting.

    Genitourinary: has indwelling catheter. Pale yellow urine. Urinary output of more than

    30 cc per hour.

    Reproductive :G2P3 (T0P2A0L3), menarche started at age 13, regular menstrual period,

    averaging 4-5 days duration w/ 28-30 days interval. Uses 2 pads per day, fully soaked,

    denies dysmenorrhea. With 2 children one aged 14 and one delivered last January 6.

    Reported use of withdrawal method as birth control

    Musculoskeletal: Ambulatory (requires assistance at times); reports muscular

    weakness (body malaise) and joint pain (arthralgia). Unremarkable edema.

    Neurologic/ Psychiatric: conscious, alert, oriented to place and people, responds to

    questions and follows commands. Has coordinated movements, intact cranial nerves.

    No memory and sensory deficit. Unremarkable sensory, motor and muscle

    coordination disturbances. Glasgow coma scale score of 15. PERRLA, no nystagmus.

    Allergic/ Immunologic/ Lymphatic/ Endocrine:No reported allergies to drugs, foods

    and insects. Has undergone blood transfusion and no negative reactions reported. No

    lymph node enlargement or tenderness.

    Vascular: unremarkable varicosities, negative for Homans sign.

    B- breasts soft, symmetrical, no lesions

    U- uterus not assessed; patient refused to take off her binder

    B- defecated once on the day of interview, normal color of stool

    B- indwelling catheter present, no hematuria, normal urine output

    L- lochia serosa, moderate amount, no foul odor

    E- stitches well-approximated, no bleeding, edema, redness, discharges, or ecchymosis

    S- skin dry and good turgor, evenly colored, ecchymosis noted

    H- homans sign absent

    E- independent, eager to see and take care of infant, no signs of depression

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    Past Medical History: Family History: Social History:

    y Chickenpox Highschooly (+) DM since 2nd pregnancy (1995) maintained on

    metformin 500mg/tab 1 tab BID. On insulin sinceNovember 2010

    y S/P CS - 1999: 3rd babyy (+) HPN since October 2010 on Nifedipine 10mg/tab

    1 tab OD and Methyldopa (AldomeT) 500mg/tab BID

    since Nov 2010 BP 180/100 UBP 120/70

    y (+) proliferative diabetic retinopathy OU s/ppanretinal photocoagulation OS (October 2010)

    Binan Doctors Hospital

    y (-) Allergy, Asthma, PTB, Thyroid Disease

    y (+) DM maternal grandmotherand parents

    y (+) HPN parentsy (+) Cancer - grandfathery (-) Allergy, Asthma, PTB, Thyroid

    Disease, CV disease

    y Non-smokery Occasional alcoholic beverage drinkery Denies use of illicit drugs

    Sexual History: Menstrual History: Obstetrical History:

    y The patients first sexualcontact happened when she

    was 21 years old with her lpm

    sexual partner.

    y (-)post-coital bleedingy (-)dyspareuniay They didnt use any family

    planning method. They usedwithdrawal most of the times.

    y Menarche: 13 years oldy Interval: 28-30 daysy Duration: 5-7 daysy Amount: 3 pads/day,

    fully soaked

    y Symptoms: nodysmenorrhea

    y LMP: Aug 15, 2010y PMP: unrecalledy AOG: 22-23 weeks by

    LMP

    Gravida Year Mode of

    Delivery

    Baby

    1 1991 Outlet

    Forceps

    Extraction

    y Female, Full termy Birth weight: 9Lbs

    2 1995 NSD y Male, Full termy (+) dystocia 2 to macrosomiay died 1 day after delivery

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    NURSING HISTORY

    Patterns of Functioning: Based on Gordons

    Typology of 11 Functional Health Patterns,

    reflected in Kozier and Erbs Fundamentals of

    Nursing (8th

    edition)

    Health-perception/ health-management pattern. (Describes the

    clients perceivedpattern ofhealthandwell-being andhowhealth ismanaged)

    When asked on how is her overall condition, the patient

    responded with ok naman. She verbalized ewan ko kung ano ang

    kalagayan ko when asked on how she sees her present health

    status. She has been accustomed with the different medical

    treatments given to her saying nasanayna. She claims that it has

    been her 6th

    admission to an institution, with previous

    hospitalizations at St. James Hospital, Laguna and the Philippine

    General Hospital, Manila.

    The patient is compliant with the different treatments,

    medications, and diagnostic examinations necessary for her case;

    except in cases of financial difficulties. The patients husband

    verbalized oo naman kung kailangan at doon gagaling, except if

    hindi kayafinancially.

    Activity-exercise pattern.(Describesthe pattern ofexercise, activity,

    leisureandrecreation)

    Patterns of activity and leisure for the patient include

    eating, cooking, and watching the television. However, due to her

    condition, her fondness for eating has decreased; with her slowly

    regaining it back with the improvement of her health. Recreations

    done as a family include going out together, and celebrating

    birthdays and occasions. The exercise she had before morbidity

    included walking while stretching the upper arms, and also with the

    workout from her performance of household chores. While

    admitted, she walks around the ward as tolerated.

    Sleep-rest pattern. (Describes the patterns of slee p, rest, andrelaxation)

    Prior to pregnancy, the patient enjoys full 8 hours of sleep

    during the night, with no difficulty in initiating it. There are no

    routines done, and she feels well rested when she wakes up in the

    morning. However, due to the experienced persistent vomiting, she

    experienced difficulty in sleeping which was described as halos

    hindi namakatulog." At present, she takes afternoon naps lasting

    around 1-2 hours, and has regained her long 8 hours of sleep during

    the night. She claims to feel rested upon waking up. There is no

    history of taking medications to aid sleep.

    The patient experienced backache with a pain score of

    10/10 relieved by massaging. She claimed that it hurts during

    activities and even at rest. The patient has difficulty in walking and

    needs partial assistance when moving and going to the CR. herhusband is the one who helped her when doing some activities.

    Nutritional-metabolic pattern.(Describestheclients pattern offood

    and fluid consumption relative to metabolic need and pattern

    indicators ofnutrientsupply)

    Prior to her 4th

    pregnancy, the patient had good appetite,

    saying she has no favorite viand in particular. She consumes rice,

    meat, fish, fruits, and mostly vegetables, at 3 to 4 times a day.

    By 2nd

    trimester, during the 3 months where the patient experienced

    episodes of persistent vomiting (described as almost every day)

    accompanied with intense abdominal pain (graded 7-8 out of 10) on

    the epigastric area, the patient was not able to consume her usual

    meals. She had about 2-3 spoons of food per meal (decreased from

    3-4 to 1-2 times per day), not able to finish the food served anddescribed as kontilang. During those months, she mostly had sips

    of water only. Her vomiting usually occurred around 3-5 times a day,

    increasing to 12 times per day (or every 3-4 hours) prior to

    admission, with around 500 ml of watery vomitus per episode, or

    amounting to her prior intake in some episodes. This nutritional

    pattern caused the patient to lose weight, her husband saying

    malakitalagaang hinulog ng katawan niya.

    At present, the patient notes that she now has an improved

    appetite. She can now finish the meals served to her with some

    effort. Her fluid consumption mostly comprised of water and fresh

    pineapple juices, totalling to around 2500 ml per day. She tries to

    replace fluids lost by drinking Gatorade and water every now and

    then, and after episodes of vomiting. She does not take any dietary

    supplements. She stands at 52, and presently weighs 123 pounds

    (taken February 2, 2011).

    Elimination pattern. (Describes the patterns of excretoryfunction:

    bowelandbladder)

    Prior to morbidity, the patient moves her bowels every

    day, usually in the morning. She usually had brownish, formedstools, which she regarded as her having a regular bowel elimination

    pattern. At present, she has difficulty moving her stools, with an

    interval of every 4 days (around 1-2 times per week). She described

    her stools as formed, hard and small, with encountered difficulty in

    evacuation. She has no history of using laxatives, but thinks that she

    may require the use of such if this bowel pattern continues.

    For bladder function, she denies difficulty in urination both

    in the past, and in the present. There is no dysuria, no urinary

    hesitancy, and no feelings of incomplete voiding. She described her

    urine as dark yellowish, which she related to her intake of

    medications. At present, she noted that her urine is already

    clearing up, described as clear and pale yellow.

    Cognitive-perceptual pattern. (Describes sensory-perceptual andcognitive patterns)

    The patient denies any decreasing function in hearing and

    feeling. She says that even before the emergence of the signs and

    symptoms of her condition, up until now, her hearing and touch

    sensation are adequate. She does not use hearing aids.

    Taste sensation changed as during the episodes of her

    persistent vomiting, she had poor sensation. She verbalized not

    being able to taste normally after episodes of vomiting, saying

    walang panlasa and that everything tasted bitter. At present, she

    says that she can now taste the foods given to her adequately, with

    her sense of taste returning to normal.

    She did not experience any significant change in her sense

    of smell, noting that she wanted the smell of bell pepper.

    Her sense of sight was noted to have a decrease infunction, for which she described as parang lumabo ang paningin

    ko. She says that this feeling of having a hazy vision appeared only

    during her hospitalization. Her husband verbalized that she was able

    to read normally before but few days after admission she was not

    able to see faces clearly that were 3 to 4 feet away from her, able to

    read only at close range and with bigger scripts. She does not wear

    eye glasses or other aids.

    There were no noted changes in the patients cognitive

    patterns. Her memory and decision making ability were consistent

    to her pre-morbid state. There were no noted changes in her

    pattern of speaking and her choice of words. There were no

    episodes of hallucinations and psychiatric disturbances.

    For pain sensation, she claims that she simply endured the

    pain she felt prior to hospitalization. This was attributed to herepisodes of persistent vomiting; causing abdominal pain (graded 7-8

    out of 10). During hospitalization, her pain tolerance decreased as

    evidenced by her verbalization naiiyak nalang ako sasakitng tiyan

    ko. During these episodes, her husband gently strokes her

    abdomen; hinihimas ko nalang hanggang samakatulog nasiyasa

    sakit as verbalized.

    Self-perception/ self-concept pattern. (Describes the clients self-

    conceptpattern andperceptions ofself)

    When asked on how she sees herself, the patient

    responded ganoon parin, walang nagbago nagkasakitlang. She

    added hindi naman ako masyadong depressed. She has good eye

    contact during the nurse-patient interaction, with an open posture,

    shoulders slightly depressed. However, she appeared sleepy andtired, apparently with tears swelling up in her eyes which she gently

    pats dry. The patients husband describes her as a jolly, thoughtful

    person who enjoys long chats and insightful conversations. He now

    describes her as tumamlay, athuminamagsalita.

    Role-relationship pattern. (Describes the clients pattern of role

    participation andrelationships)

    The patient lives with her husband, her daughter who is 19

    years old, her son who is 13 years old, and her mother. They live in a

    compound with their immediate relatives. She has a 20-year

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    relationship with her husband, described as magandaang relasyon

    namin. May mga tampuhan man, pero normal naman iyon.

    Magandaang communication namin. They have a strong bond as a

    family, for which every member has accepted the present condition

    of the patient. Their near relatives help by giving financial support.

    However, their children are not able to visit her in the hospital. Her

    husband verbalized naaawa ako sa anak namin, tuwing nakikita

    nila siya na ganyan, alam ko na nalulungkot sila. She, being the

    mother of the household, is in charge with the chores and managing

    their carinderia/sari-saristore. But with her present state, she is not

    able to perform her responsibilities.

    Sexuality-reproductive pattern. (Describes the clients patterns of

    sexualandproductive patterns)

    The patient and her husband share a strong bond, with the

    husband supporting her all throughout her treatments and

    hospitalizations. It is evident that they have a satisfying husband and

    wife relationship, with one giving love and support to the other

    when in need. The couple makes decisions together, allowing an

    open communication between them. Her husband would massage

    her saying that it helps her feel better and fall asleep. He also

    provides emotional support by always encouraging her to get well as

    soon as she can and that she does not need to exert herself because

    he and their children will take care of the matters at home. She and

    her husband are considering her undergoing bilateral tubal ligationafter the birth of their 4th child.

    Coping/ stress-tolerance pattern. (Describes the clients general

    coping pattern andtheeffectiveness ofthe pattern in terms ofstress

    tolerance)

    The situations identified by the patient as stressful are

    generally those of their financial difficulties and how they would be

    facing their everyday needs. One problem identified was the

    spending of all their savings for her treatments. Other than financial

    troubles, she says wala naman akong problema, tama lang

    kuntento. Coping with stress is primarily aided by her family and

    friends who act as her major support system. She adds that living ina compound with her relatives helps in her management of

    problems.

    Value-belief pattern. (Describesthe patterns of values, beliefs, and

    goalsthatdirecttheclientschoicesanddecisions)

    The patient values her family, and prioritizes it. She cares

    for their traditions and sticks to what they have done for the past

    years such as celebrating occasions. Their family celebrations were

    described as hindi pwedeng walang handa. One social value

    mentioned was respect. She values respect not only for the older

    people, but also for the younger ones. As Roman Catholics, the

    patients family attends mass as a group regularly. Her goal at

    present, as quoted, siyempre, dapatgumaling.

    COURSE IN THE WARD

    DATE FOCUS MANAGEMENT

    January 3, 2012 Admission, high blood

    pressure, Anemia

    Elevated levels of BUN, BUA,

    creatinine and LDH

    Albuminuria, hematuria

    Glycemic control

    Mixed vaginal infection

    Monitored VS q15 mins

    Monitored FHT q15 mins

    Started IVF D5NR 1L @ 20 gtts/min; Nicardipine 10 mg + 90 cc PNSS to run @ 10

    gtts/min

    Titrated to maintain BP 140/90

    Given MgSO4 4g/SIVP then 5g each buttockRequested for:

    y CBG with platelet county Uric Acidy BUN, creatininey SGPT, SGOTy Lactose dehydrogenase, Blood uric acidy 24h urine protein

    ON NPO

    Referred to Rheumatology & Endocrinology and to Perinatology for co-management

    BPS with Doppler studies; Fetal counting movement

    Started Hydrocortisone 60mg/IV q12h

    Patients diet: light meals on low fat

    For C3

    Resumed Prednisone 30 mg 1 tab OD after breakfast

    Revised diet as follows: 30 kcal/kg/BW

    +200 kcal (pregnancy), 40% CHO

    +20% CHON +40% FATS, low salt, low cholesterol diet divided as follows:

    10% breakfast

    30% lunch

    30% dinner

    30% divided into 3 snacks to be taken 2 hours after each main meal

    Gave Hunalog 8 u/SC and HN 14 u/SC

    Revised standing insulin as follows:

    Humulin N Hunalog

    Prebreakfast 14 8

    Prelunch - 8Predinner 10 8

    Monitored CBG 1h after each meal

    Facilitated thyroid function test

    At 4pm, IC was removed

    Started Methyldopa 500 mg TID

    Increased Prednisone to 50 mg/tab, Started Neo Penstran suppository

    Consumed IVF D5NR 1L @ 20 gtts/min, started PNSS 1L 20 gtts/min

    Revised Insulin supplementation as follows:

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    Humulin 70/30 Humulog

    Pre breakfast 22 8

    Pre lunch - 8

    Pre dinner 12 8

    Treated SLE flare

    Started Neo Penstran vaginal, suppository 1 suppository at bedtime for 7 days

    Jan 4 BP: 140-150/90 DTRs ++

    FHT 140bpm

    Reactive NST

    Pale Palpebral conjunctiva,

    anicteric sclera, clear Breath

    sounds, globular abdomen

    FH: 29cm

    FHT: 128 bpm

    Started Humulin 70/30 as follows:

    Pre breakfast: 30Pre dinner: 20

    *both per SC

    Continued CBG monitoring 1 hour post meals

    Monitored VS and FHT q2h and recorded

    Maintained Nicardipine drip at 7-8 mcgtts/min

    Maintained BP @140/90

    Counted fetal movement

    Held Methyl dopa

    Resumed Hydrochloroquine 200 mg/tab 1 tab OD

    Caltrate tab 1 tab OD

    Ranitidine 150 mg/cap, 1 cap OD

    Instead of BPS & NST once weekly

    Did NST this day

    BPS Friday

    NST Sunday

    BPS Tuesday

    NST Thursday

    BPS Sat

    Monitored UO q4h and recorded

    Jan 7 BP: 130-140/90

    RR 20

    Afebrile

    PR 98 full

    Clear breath sounds

    Uterus well contracted

    UO:35-50cc/hr

    CVP 9-11

    Still on epidural morphine

    3. BP 130-140/90

    UO 30 cc/h

    Abdomen soft nontender

    (-) bowel sounds

    Morphine 2 mg/10cc given

    Gave Morphine precaution

    Gave diphenhydramine 50mg/IV q8h PRN for pruritus

    Continued CBG monitoring every 4 hours while on NPO

    Encouraged deep breathing exercises

    Watched out for dyspnea or signs of respiratory distress

    Transferred 1 unit pRBC, held D5NR + 10 u oxytocin while on blood transfusion

    Gave Pre Blood Transfusion meds:

    y Paracetamol 300 mg/IVy Diphenyldeamine 50 mg/IV

    Gave Nicardipine 10 mg in 90 cc D5W titrate to maintain BP 120-130/80-90

    Continued hydrocortisone 100mg/IV every 8h

    Decreased CBG monitoring to q8h (6A-2P-10P)

    May have sips of waterHigh back rest

    Applied abdominal binder

    Deep breathing exercises

    Referred if UO is less than or equal to 30cc/hr

    Gave Amlodipine 5mg/tab 1 tab OD

    Turned patient from side to side

    Facilitated transfer of 2nd

    unit of PRBC

    Repeated CBC w/ platelet 12h post Blood transfusion

    Started patient on Tramadol 50 mg + Paracetamol Dolcet 1 tab (q8h)

    DERMATOLOGY Assessed for Molluscum Contagosum

    *For nick curettage as outpatient

    Noted RHEUMATOLOGY plans for anticoagulant therapy

    Epidural catheter removed and visualized by patient and relative

    No bleeding, no hematoma, no signs of infection noted on insertion siteStill with Morphine precautions

    Gave Tramadol 50 mg/SIVP q8 PRN

    For open dressing the morning after. Prepared materials at bedside

    Encouraged ambulation

    Jan 8 Input:2465 ml; Urine Output:

    43cc/hr

    Gave Pre BT meds:

    y Paracetamol 500 mg/tab 1 taby Diphenhydramine 50 mg/cap 1 cap

    Continued Nicardipine drip to follow 10 mg in 90 cc D5W to run @ 40 gtts/min to

  • 8/3/2019 Case Pres Output

    8/13

    BP 150/100

    Clear Breath sounds

    PR 95 CVP 7-8

    Creatinine 1.03 from 1.28

    maintain BP 120-130/70-80

    IVF TF (CVP): PNSS 1L to run at 10 gtts/min

    Repeated CBC post transfusion

    Continued to watch for any signs of bleeding

    Decreased hydrocortisone to 100 mg/IV q12h

    Did accurate IO monitoring per shift and recorded

    Referred if UO 160/100mmHg

    Discontinued oxytocin containing IVF

    Hooked to 1L D5NSS @ 20 gtts/minShifted Amoxicillin to Co-amoxiclav 625 mg/cap BID to complete for 7d

    CVP converted to peripheral line

    January 9 BP 140/100

    PR 79 RR 18 T 36

    Pink conjuctiva

    Clear breath sounds

    (-) dyspnea, no acute

    pulmonary problems right now

    Problem 1: +palpitations and

    tremors

    HPN since 2009, no flushing,

    headacheProb 2: Vit D insufficiency; on

    steroids

    Monitor CBG TID 2 hours post

    meals

    Prob #3: DM vs Steroid

    induced hyperglycemia

    compromising appetite

    CBGs controlled

    Plan: to taper steroid dose

    today

    Soft abdomen, well contracted

    uterus

    Normal lochia, (-BM)

    +flatus

    DTR ++

    Encouraged early ambulation

    Referred for episodes of tachycardia

    Monitored CBG TID 2 hours post meals

    Started CaCO3 600 mg + Vit D 200 mg/tab

    Caltrate plus 1 tablet TID after meals

    Started Vit D 200 mg/cap 1 cap OD after lunch

    Planned to screen for osteoporosis as outpatient

    Gave last dose of Hydrocortisone 100mg/IV @ 12 noon

    Resumed Hydroxychloroquine 200 mg/cap 1 cap OD

    Resumed Nicardipine drip to follow: 10mg Nicardipine in 90cc D5W to run @10mcgtts/min and titrate to maintain BP 120-130/70-80

    Decreased BP monitoring to q2h

    CVP line pulled out

    IVF to follow: PNSS 1L to run @15gtts/min

    Jan 10 BP range 140-190/100; 120-

    130/80-90

    Clear breath sounds

    Well contracted uterus

    Normal lochia

    DTRs +++ (hyperactive deep

    tendon reflex)

    (+) epigastric pain radiating to

    the back(-) blurring of vision

    (+) headache

    Improving appetite

    (-) bowel movements for 5

    days

    *Ideally, CBC, SGPT, SGOT LDH

    and BUA should be repeated

    for HELLP work up. However,

    d/t financial constraints, we

    will prioritize current

    medications of the patient.

    7. PR 74

    (-) dyspnea

    (-) chest pain

    Adequate Urine Output

    PR 74 RR 18 T 36.5

    (+) bowel movement

    Patient agitated due to pain

    Currently weak looking

    Shifted Hydrocortisone to Prednisone 30 mg/tab, 1 tab OD after meals

    Nicardipine drip to follow:

    10mg Nicardipine in 90cc D5W to run at 20mcgtts/min

    Referred if BP>140/90

    Ambulation as tolerated

    Started preparing discharge papers

    Gave MgSO4 4g/IV, 5g/IM on each buttock

    Inserted Foley catheter after giving IV dose of MgSO4

    Gave Omeprazole 40mg/tab OD prebreakfast

    Requested for:y CBC with platelety SGPT, SGOTy LDH, uric acid

    Continued CBG monitoring TID 2 hours post meals

    Continued BP monitoring q1

    Titrated Nicardipine to maintain BP @ 120-130/80-90

    After IV dose of Omeprazole, shifted to oral 40mg OD prebreakfast

    Increased Metoprolol dosage to 100mg/tab 1 tab BID

    Referred if with epigastric pain, headache, dizziness

    Regulated Nicardipine 10 mg Nicardipine in 90cc PNSS to run @ 10 mcgtts/min

    Gave Ranitidine 50mg/IV now

    Patient was NPO

    Shifted on D5 containing IVF D5NR 1L @ 20 gtts/min

    CBG q4 while on NPOFacilitated CBC, SGPT, SGOT Crea, LDH and BUA

    Increased Ranitidine to 50mg/IV to q12h

    Monitored VS q1h including GCS, pupillary light reflex and O2 saturation

    Revised CBG monitoring to q6h

    Gave Demerol 25mg/IV for severe pain

    Shifted Co-amoxiclav to Ampicillin 500mg/IV q8h

  • 8/3/2019 Case Pres Output

    9/13

    January 11 Maintain blood pressure, Pain

    control

    IVF to follow D5LRS 1L @ 20gtts/min

    Nicardipine drip to follow:

    10 mg Nicardipine in 90cc D5Water to run @35 gtts/min to maintain BP @ 120-

    130/70-80 mmHg

    Followed up official LGBPS result

    LABORATORY EXAMS & DIAGNOSTIC PROCEDURES

    Vitamin D Immunoassay: January 3, 2012 (USTH)25.3 ng.mL 30

    Complete Blood Count: January 3, 2012 (USTH)

    Complete Blood Count Result Unit Reference

    Range

    HGB 89 (LOW) g/l 120-170

    RBC 2.89 (LOW) X 10 ^12/L 4.0-6.0

    HCT 0.26 (LOW) 0.37-0.54

    MCV 90.60 U^3 87 5

    MCH 30.90 Pg 29 2

    MCHC 34.10 g/Dl 34 2

    RDW 13.90 11.6-14.6

    MPV 8.70 fL 7.4-10.4

    PLATELET 200 X10^9/L 150-450

    WBC 9.80 X10^9/L 4.5 10.0

    DIFFERENTIAL COUNT

    NEUTROPHILS 0.70 0.50 0.70

    METAMYELOCYTES -

    BANDS - 0.00 0.05

    SEGMENTERS 0.70 0.50 0.70

    LYMPHOCYTES 0.30 0.20 0. 40

    MONOCYTES - 0.00 0.07EOSINOPHILS - 0.00 0.05

    BASOPHILS - 0.00 0.01

    Complete Blood Count: January 05, 2012 (USTH)

    Complete Blood

    Count

    Result Unit Reference

    Range

    HGB 110 g/l 120-170

    RBC 3.53 X 10 ^12/L 4.0-6.0

    HCT 0.32 0.37-0.54

    MCV 90.00 U^3 87 5

    MCH 31.30 Pg 29 2

    MCHC 34.80 g/Dl 34 2

    RDW 13.80 11.6-14.6

    MPV 8.70 fL 7.4-10.4

    PLATELET 209 X10^9/L 150-450

    WBC 11.7 X10^9/L 4.5 10.0

    DIFFERENTIAL

    COUNT

    NEUTROPHILS 0.88 0.50 0.70

    METAMYELOCYTES -

    BANDS - 0.00 0.05

    SEGMENTERS 0.88 0.50 0.70LYMPHOCYTES 0.12 0.20 0. 40

    MONOCYTES - 0.00 0.07

    EOSINOPHILS - 0.00 0.05

    BASOPHILS - 0.00 0.01

    Complete Blood Count: January 06, 2012 (USTH)

    Complete Blood

    Count

    Result Unit Reference

    Range

    HGB 78 g/l 120-170

    RBC 2.44 X 10 ^12/L 4.0-6.0

    HCT 0.22 0.37-0.54

    MCV 90.90 U^3 87 5

    MCH 31.90 Pg 29 2

    MCHC 35.10 g/Dl 34 2

    RDW 14.30 11.6-14.6

    MPV 8.10 fL 7.4-10.4

    PLATELET 179 X10^9/L 150-450

    WBC 22.60 X10^9/L 4.5 10.0

    DIFFERENTIAL

    COUNT

    NEUTROPHILS 0.90 0.50 0.70

    METAMYELOCYTES -

    BANDS - 0.00 0.05

    SEGMENTERS 0.90 0.50 0.70

    LYMPHOCYTES 0.10 0.20 0. 40

    MONOCYTES - 0.00 0.07

    EOSINOPHILS - 0.00 0.05

    BASOPHILS - 0.00 0.01

    Complete Blood Count: January 08, 2012 (USTH)

    Complete Blood

    Count

    Result Unit Reference

    Range

    HGB 126 g/l 120-170

    RBC 3.99 X 10 ^12/L 4.0-6.0

    HCT 0.36 0.37-0.54

    MCV 89.50 U^3 87 5

    MCH 31.50 Pg 29 2

    MCHC 35.20 g/Dl 34 2

    RDW 13.80 11.6-14.6

    MPV 8.10 fL 7.4-10.4

    PLATELET 228 X10^9/L 150-450

    WBC 25.00 X10^9/L 4.5 10.0

    DIFFERENTIAL

    COUNT

    NEUTROPHILS 0.93 0.50 0.70

    METAMYELOCYTES -

  • 8/3/2019 Case Pres Output

    10/13

    BANDS - 0.00 0.05

    SEGMENTERS 0.93 0.50 0.70

    LYMPHOCYTES 0.07 0.20 0. 40

    MONOCYTES - 0.00 0.07

    EOSINOPHILS - 0.00 0.05

    BASOPHILS - 0.00 0.01

    Complete Blood Count: January 10, 2012 (USTH)

    Complete Blood

    Count

    Result Unit Reference

    RangeHGB 111 g/l 120-170

    RBC 3.51 X 10 12/L 4.0-6.0

    HCT 0.31 0.37-0.54

    MCV 88.80 U^3 87 5

    MCH 31.60 Pg 29 2

    MCHC 35.60 g/Dl 34 2

    RDW 13.70 11.6-14.6

    MPV 8.50 fL 7.4-10.4

    PLATELET 140 X10^9/L 150-450

    WBC 14.70 X10^9/L 4.5 10.0

    DIFFERENTIAL

    COUNTNEUTROPHILS 0.89 0.50 0.70

    METAMYELOCYTES -

    BANDS - 0.00 0.05

    SEGMENTERS 0.89 0.50 0.70

    LYMPHOCYTES 0.11 0.20 0. 40

    MONOCYTES - 0.00 0.07

    EOSINOPHILS - 0.00 0.05

    BASOPHILS - 0.00 0.01

    Complete Blood Glucose Monitoring

    Date Time Result Action

    1/7/2012 10AM 84mg/dL

    3PM 68mg/dL

    10PM 73mg/dL

    1/8/2012 6AM 98mg/dL RELAYED

    2PM 120mg/dL

    10PM 147mg/dL

    1/9/2012 6AM 149mg/dL

    2PM 142mg/dL

    9PM 207mg/dL RELAYED

    1/10/2012 2p BF 129mg/dL RELAYED

    2 p Lunch 139mg/dL

    CBG q4

    while on

    NPO

    6PM 173mg/dL

    10PM CBG q6

    1/11/2012 12AM 222mg/dL RELAYED;

    Given

    Humulin R,

    1 unit given

    per SC

    6AM 190mg/dL

    Blood Chemistry: January 03, 2012 (USTH)

    Result Unit Reference

    Range

    Urea

    Nitrogen

    36.15 mg/dL 9-23

    Blood uric

    Acid

    9.92 mg/dL 2.7 7.3

    Creatinine 1.52 mg/dL 0.5 1.2

    SGOT 20.15 0 32

    SGPT 14.85 0 31

    LDH 274.59 100 190

    Sodium 137.0 mmol/L 137 147

    Potassium 4.75 mmol/L 3.8 5

    Complement

    Factor 3

    g/L 0.9 1.8

    Ionized

    Calcium

    mmol/L 1.12 1.32

    Amylase u/L 10 130

    Lipase u/L 13 60

    Magnesium mg/dL 4-7 mg/dL

    Blood Chemistry: January 05, 2012 (USTH)Result Unit Reference

    Range

    Urea Nitrogen mg/dL 9-23

    Blood uric Acid mg/dL 2.7 7.3

    Creatinine 1.28 mg/dL 0.5 1.2

    SGOT 0 32

    SGPT 0 31

    LDH 374.00 100 190

    Sodium mmol/L 137 147

    Potassium mmol/L 3.8 5

    Complement

    Factor 3

    0.56 g/L 0.9 1.8

    Ionized

    Calcium

    mmol/L 1.12 1.32

    Amylase u/L 10 130

    Lipase u/L 13 60

    Magnesium mg/dL 4-7 mg/dL

    Blood Chemistry: January 08, 2012 (USTH)

    Result Unit Reference

    Range

    Urea Nitrogen mg/dL 9-23

    Blood uric Acid mg/dL 2.7 7.3

    Creatinine 1.03 mg/dL 0.5 1.2

    SGOT 0 32

    SGPT 0 31

    LDH 100 190

    Sodium 141.0 mmol/L 137 147

    Potassium 4.04 mmol/L 3.8 5

    Complement

    Factor 3

    g/L 0.9 1.8

    Ionized

    Calcium

    mmol/L 1.12 1.32

  • 8/3/2019 Case Pres Output

    11/13

    Amylase u/L 10 130

    Lipase u/L 13 60

    Magnesium mg/dL 4-7 mg/dL

    Blood Chemistry: January 10, 2012 (USTH)

    Result Unit Reference

    Range

    Urea Nitrogen mg/dL 9-23

    Blood uric Acid 5.59 mg/dL 2.7 7.3Creatinine 0.87 mg/dL 0.5 1.2

    SGOT 0 32

    SGPT 71.41 0 31

    LDH 100 190

    Sodium mmol/L 137 147

    Potassium mmol/L 3.8 5

    Complement

    Factor 3

    g/L 0.9 1.8

    Ionized

    Calcium

    1.03 mmol/L 1.12 1.32

    Amylase 130.13 u/L 10 130

    Lipase 15.36 u/L 13 60Magnesium 5.76 mg/dL 4-7 mg/dL

    Blood Typing: January 06 & 07, 2012

    ABO Blood Group and Rh factor A POSITIVE

    Coagulation Assay: Januray 06, 2012

    Results Reference Range

    Prothrombin Time 10.8 secs 10.3 14.1 secs

    Normal control 12.0 secs

    Prothrombin Ratio 0.9

    InternationalNormalized Ratio 0.9 0.8 1.3

    Activated PTT 32.0 secs 27.0- 45.4

    Normal control 33.5 secs

    Urinalysis: January 3, 2012

    Results

    Color Light yellow

    Transparency Slightly turbid

    pH 6.0

    Specific gravity 1.020

    Albumiin ++

    Sugar NegativeLeukocytes Negative

    Erythrocytes Positive

    Bilirubin Negative

    Nitrates Negative

    Ketones Negative

    Urobilinogen Normal

    RBC 60-70/hpf

    Pus cells 0-1/ hpf

    Hyaline cast 05/coverslip

    Transitional Epithelial Cell FEW

    Squamous Cell

    Renal Cell

    Bacteria FEW

    y No dysmorphic RBC seenUrinalysis: January 5, 2012

    Results

    Color Light yellow

    Transparency Slightly turbid

    pH 7.0

    Specific gravity 1.010

    Albumin +++

    Sugar Negative

    Leukocytes Negative

    Erythrocytes Positive

    Bilirubin Negative

    Nitrates Negative

    Ketones Negative

    Urobilinogen Normal

    RBC 2-4/hpf

    Pus cells 0-2/hpf

    Hyaline cast

    Transitional Epithelial Cell

    Squamous Cell FEW

    Renal Cell FEW

    Bacteria FEW

  • 8/3/2019 Case Pres Output

    12/13

    DIAGNOSTIC EXAMS

    Ultrasound Report: Jan 03, 2012 (University

    of Santo Tomas Clinical Division)

    Impression: The remarks for this ultrasound: Single, live,

    intrauterine Pregnancy of about 30-31 weeks, breech

    Number Single

    Presentation Breech (Floating)

    BPD 8.07

    HC --

    AC --

    FL 5.66

    Average

    AOG

    30-31 weeks

    Fetal Cord

    Vessels

    2 Arteries: 1 Vein

    FHR 126 bpm

    Sex NOT INCLUDE

    DPlacenta Anterior, Grade II

    Amniotic

    fluid

    14.22

    SEFW 1406grams

    FAC 24.31 cm

    A Biophysical scoring was done and it reports that:

    Amniotic Fluid 2/2

    Body Movement 2/2

    Fetal Tone 2/2

    Fetal Breathing 2/2

    Total 8/8

    Doppler velocimetry was done. It reported that S/D is 2.17.

    PI: 0.77. RI:0.54.

    Ultrasound report: Single, live, intrauterine Pregnancy of

    about 30-31 weeks, breech

    BPS: 8/8, SEFW= 1406 grams.

    Normal umbilical artery Doppler indices

    12-Lead ECG: January 6, 2012

    - Sinus RhythmChest X-Ray

    Chest X-Ray: January 06, 2012

    -The heart appears enlarged

    -Slight prominence of pulmonary vesicular markings

    is noted

    -Both diaphragms are elevated

    -Sinuses are intact

    Xray report: probable cardiomegaly, consider mild pulmonary

    congestion

    Portable Chest Xray

    - Follow-up chest X-Rayfew hours nowshows a CVP line in place with its tip at

    the level of the right ventricle. Suggest

    revision. The rest of the findings remain

    unchanged

    Sledai Scoring

    y See attached scoring sheetConclusion: Mild Flare

    ULTRASOUND REPORT: January 10, 2012

    - The liver is within normal range in size.A well- circumscribed hypoehcoic

    stucture is seen in segment VI of the

    liver measuring 1.92 x 2.01 x 2.1 cm (AP

    x W x H).

    - The gallbladder measures 2.7 cm indiameter which is within normal range.

    Medium level echoes are noted within

    the lumen that shows free movement

    during maneuvers. The wall measures

    0.7 cm

    - Pancreatic head is 3.7 cm, body is 1.7cm and tail is 1.4 cm. negative for mass

    in or at the region of the pancreas.

    - Moderate peritoneal fluid is appreciated.There is likewise minimal fluid accumulationin the perirenal region.

    - Spleen is not enlarged. Negative for intra-splenic mass.

    - Incidentally, minimal pleural effusion on theright is noted. Minimal pericardial fluid

    likewise seen.

    - Echopattern of both kidneys are diffuse.

    Impression: Hepatic cyst, Segment VI. Normal sized

    gallbladder with bile sludge. Non-specific enlargement

    of the pancreatic head with non-dilated pancreaticducts. Moderate peritoneal flid collection with minimal

    perirenal fluid accumulation. Incidental findings of

    minimal pleural effusion, right and pericardial effusion.

    Incidental finding of diffuse parenchymal renal changes.

  • 8/3/2019 Case Pres Output

    13/13

    MEDICATIONS

    Date Medications

    1/3/12 Hydrocortisone 60mg/IV

    Prednisone 30mg/tab afterbfast

    Humulin N 14 units/SC pre bfast

    Humulin N 10 units/SC pre bfastHumalog 8 units/SC pre bfast

    Humalog 8 units/SC pre lunch

    Humalog 8 units/SC pre dinner

    Methyldopa 500mg/tab TID

    Prednisone 50mg/tab 1 tab OD

    Neopenotran Vaginal

    suppository;suppository @

    bedtime 7 days

    Humulin 70/30 30 u/sc pre bfast

    Humulin 70/30 10u/sc pre

    dinner

    Prednisone 30mg/tab bfast OD

    Predinisone 20mg/tab dinner

    OD

    1/6/12 Tramadol 50mg/IV PRN x pain

    score >4 q8

    Metoclopramide 10mg/Isive

    PRN q8

    Diphenhydramine 50mg/IV PRN

    pruritus

    Dolcet tab q8Hydrocortisone 100mg/IV q12

    Paracetamol 700mg/IV when in

    NPO

    Ranitidine 50mg/IV

    Ampicillin 1g/IV

    1/8/12 Amlodipine 10mg/tab OD

    Hydrocortisone 100mg/IV

    Metoprolol 50mg/tab

    Co-amoxyclav 625mg/tab 7 days

    1/9/12 Prednisone 30mg/tab p meal

    OD 12pm

    Calvit/Caltrate plus tab p meal

    TD 6pm,2pm

    Vit D 800iu/cap p meal OD 8pm

    Hydroxychloroquine 200mg/cap

    OD 8am

    1/10/12 Omeprazole 40mg/tab OD prebfast 6am

    Metoprolol 100mg/tab BID

    6am,6pm

    Ranitidine 50mg/IV 2am,2pm

    HAA 100mg/IV q12 3am,3pm

    Ampicillin 500mg/IV q8

    STAT orders

    1/3/12 MgSO4 4gm/IV

    MgSO4 5gm/IV L

    MgSO4 5gm/IV R

    Humalog 8u/sc L arm

    Humulin N 14u/SC R arm

    1/10/12 Esomeprazole 40mg/IV

    Dulcolax 20mg

    Ranitidine 50mg/IV

    HAA 100mg/IV

    MgSO4 5g/IV

    1/11/12 MgSO4 5g/IV

    PRN order

    1/11/12 Humalog 3u/sc