3
History
HISTORY OF PRESENT PREGNANCY:
LMP: May 9,2017 AOG by LMP: 39 weeks 2 days EDC by LMP: February 12, 2018 PMP: April 8, 2017 AOG by EUTZ: 39 weeks 3 days EDC by EUTZ: February 12, 2018
4
History
HISTORY OF PRESENT PREGNANCY:
Second Trimester
* Quickening was felt on the 5th month of pregnancy (October 2017). * She had regular intake of Multivitamins 1 tab daily, Ferrous sulfate 1 tablet once a day, and Calcium 1 tablet twice a day. Only urinalysis was done at the health center revealing that she had urinary tract infection. she was prescribed Cefuroxime 500mg BID for 1 week to which she was compliant. * Transabdominal ultrasound for gender determination was done on the 7th month of pregnancy revealing single intrauterine pregnancy compatible to 28 weeks and 4 days age of gestation (November 2017). * She denies any history of accidents, trauma, illness, or any exposure to radiation and toxic chemicals.
Far Eastern University - Institute of Nursing
FEU NRMF HOSPITAL
OBSTETRICS WARD
CASE PRESENTATION
Group Three Peng Sijing (Stone ), Li Xiaojing (Cathy ), Miao Chunmei (Mano), Nie Fengyan (Zara)
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History
Third Trimester
* Subsequent prenatal check-ups were regular as well as intake of multivitamins 1 tablet once a day, Ferrous sulfate 1 tablet once a day, and calcium 1 tablet twice a day. * Capillary blood glucose monitoring and 75g OGTT was done which revealed increased results. Exact values were unrecalled by the patient. She was prescribed with Novo Rapid insulin, 4 units taken 2 hours post meals. She was also advised to do capillary blood glucose monitoring at home. * Subjective complaints experienced included headache and dizziness. No hypogastric pain, abnormal vaginal discharge, vaginal spotting, dysuria, and fever. She denies any history of accidents, trauma, illness, or any exposure to radiation or toxic chemicals
First Trimester
* On the 1 month of missed period (June 2017): cessation of menses, nausea and vomiting. Self-pregnancy test was done, which revealed a positive result. * She consulted a private obstetrician where diagnostic tests such as complete blood count, urinalysis, VDRL/RPR and hepatitis B antigen screening were done. All revealed normal results except for urinalysis which revealed urinary tract infection. She was prescribed Cefuroxime 500mg BID for 1 week, and repeat urinalysis afterwards was normal. * Transvaginal ultrasound for pregnancy evaluation revealed a single intrauterine pregnancy compatible to 15 weeks and 2 days age of gestation (August 2017). * She was given multivitamins and Folic acid 1 tablet once a day which she took regularly. * She denies any history of accidents, trauma, or any exposure to radiation and toxic chemicals. * Patient had an episode of colds and took cefuroxime 500mg twice a day for 5 days. * She also took Loratadine 10mg once daily for her allergic rhinitis.
C ontent
1 Introduction
2 History
3 Physical Assessment
4
Laboratory and Diagnostic Exams.
5 Medications and IV fluid
6 Nursing Care Plan
2பைடு நூலகம்
Introduction
Patient A, 30 years old, G1P0, pregnancy uterine 39weeks and 2 days, cephalic in labor, admitted at FEUNRMF HOSPITAL on February 8, 2018. CHIEF COMPLAINT: Hypogastric Pain