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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
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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