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PT HX

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Mackie Morales
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18 views5 pages

PT HX

Uploaded by

Mackie Morales
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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Patient L.M.

O, a G1P0, 23 year old female, experienced prodromal labor 1 week


prior to admission. Despite knowing she is due any time, patient did not go to the
hospital as she deemed it not yet necessary.

Due to financial constraints and the distance of her home from the facility, she
only had two prenatal visits: the first on May 24, 2024, with a blood pressure of
100/80 mmHg, a weight of 48 kg, and an age of gestation (AOG) of 27 weeks and
2 days; the second on June 14, 2024, with a blood pressure of 100/90 mmHg, a
weight of 51 kg, and an AOG of 30 weeks and 2 days. However, her ultrasound on
July 2, 2024, revealed that there was a nuchal cord present. As she was unable to
return for further visits, this issue was not addressed. Her last check-up was on
June 14, 2024 ,unfortunately, the record cannot be retrieved in admitting section.
she claimed to be diligent in taking her prenatal vitamins and did not experience
any unusual signs or symptoms.

A day prior to admission, patient L.M.O. came to the ER twice for labor and
delivery assessment, she was discovered to be 41 weeks and 2 days pregnant by
LMP and 40 weeks and 6 days pregnant by ultrasound. She had normal vital signs
and weighed 55kgs, FH of 28cm, FHB was 144bpm at the LLQ, cephalic in
presentation and with an intact bow and an IE of 1-2cm. Due to the age of her
pregnancy, she was appraised of possible referral if labor would not progress
within the next 24 hours.
AUGUST 30, 2024

According to the OPD Chart, patient 1st came to the ER with labor pains last
August 30 at 7:15am and presented with an IE of 1cm and a (+) bow. Advised
to come back once labor progresses and was for possible referral due to post
term pregnancy.

Her vital signs were recorded as follows:


BP: 120/80 mmHg
Temp - 36.7c
CR: 91 bpm
RR - 23 bpm
O2 sat: 97%

Other assessment:
FH - 28 cm
FHB- 140 LLQ

On the same day at 5:35pm, patient came back and revealed to be 2cm dilated
with still intact bow. Advised to return again as active labor begins at 4cm.

Her vital signs were recorded as follows:


BP: 100/80 mmHg
Temp - 36.7c
CR: 103 bpm
RR - 21 bpm
O2 sat: 98%

Other assessment:
FH - 28 cm
FHB- 143 LLQ

Dr. M as the first to have seen her.


AUGUST 31, 2024

The next day August 31, 2024 at 1140 am , patient was seen and assessed with
3cm dilation and with an intact bow. Still, advised to come once on active
labor.

Her vital signs were recorded as follows:


BP: 100/80 mmHg
CR: 81 bpm
O2 sat: 98%

Other assessment:
FH - 28 cm
FHB- 139 RUQ

Later in the evening, patient came at the ER at 9:10pm, IE= 4cm and with
leaking bow, noting that previous weight was @ 55kgs but is now 53.9kg. IV
line started with D5LR 80cc/hr @ inserted at Left Cephalic vein.

Her vital signs were recorded as follows:


BP- 120/90
Temp- 36.1 c
PR - 92 bpm
RR - 21 bpm
O2 sat - 99%

Other assessment:
FH - 28 cm
FHB - 138 RLQ

9:50pm, HNBBxdoses given. However, as labor still did not progress, oxy drip
was started and ampicillin was loaded. (Patient is negative in skin test to
ampicillin prior administration)

Dr. L and Dr. G attended to her on August 31 until she was admitted by Dr. G
at midnight on September 1, 2024. On that same day, the baby boy was
delivered at 5:40 AM under the care of Dr. Lee.
Maternal Assessment:
(+) labor pain
(+) FH 36cm?
(+) FHB 140 LLQ or RLQ

G1P1KENEME AMBAY via NSVD to a kenemrloo


BB Boy AGA
A5 9 (sorry maam yawan nko garilibat nko) 3.1 kg
:

September 1, 2024
Physicians order: Repeat keneme, for removal of keme ? (Tabang maam
Cla :( )
9:25am: Request 3 units PRBC
Hb: 74
Hct: 22
RBC: 23
WBC: 14

September 2, 2024
-for proper countercheckimg of available chem? Hahah may transfuse
kemerloooo

September 3, 2024
• repeat CBC, transfuse avaialbale units of PRBC
• keneme to KVO
September: 4, 2024
7am: BT orders:
• transfuse 1 unit PRBC of pt. FeSO4 _ FA 1 cap Bid

September 7, 2024
• given FeSO4 + FA 1 cup BID
• Mefenamic acid 500mg q6h prn for pain
• Cefalexin 500mg TID x 1 (patawara ko maam)
• OPD ff up checkup after 1 week

September 9, 2024
8:58am: follow upo checkup
BP 100/70
T 36.4
PR: 80
RR:20

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