Malacaste, Elaine Tanena 37 years old

Diagnosis/Clinical Impression & Chief Complaint: G4P3 Pregnancy Uterine

34-35 weeks;
CAVD; superimposed pre-eclampsia;
several features; partial HELLP; impending
eclampsia

Place of Origin: 3/6/16 6AM DRPD (DR Pay Division)

Code: RE (back to room) post ECS 3/6/16 6:03AM SCAT

S-B-A-R Hand of

Situation
Awake patient

YES

NO

Sedated PT

PT with airway device

VS Stable

VS Guarded

VS Critical
Background

YES

Pre-op/ Pre-procedure
NPO time

Surgical site marking

Post up/post procedure

Had Gen. Anaesthesia

Had Spinal/ Epidural/ CSE
Anaesthesia
Had regional/ peripheral block

NO

Post- IV sedation
Assessment

YES

NO

w/ critical event

Post-CPR/ Post-Arrest

Need further consultation/ Referral

Need blood transfusion, X-match/

Fluids
Need blood reservation

w/ Drug infusion (inotrope, dilators,

etc.)

Check CBG

w/ contraptions

Recommendation

YES

Intensive monitoring by doctor &

nurse
Intensive monitoring by nurse

NO

Regular monitoring by nurse

Sensitivity test

Specify drug

profurex

Allergy to drug skin test made

Pertinent Medical history

YES
Allergy/ history of allergy

NO

Asthma/ history of asthma

w/ sleep apnea risks

Diabetes

Hypertension on medications

Observed oliguria to anuria

On dialysis

Voiding freely/ adequate urine

output

CV risk assessment (moderate to

high)

Pertinent PE

YES
Insert BP/ PR

130/90

Insert temperature

36.9

If available, note SPO2 on

endorsement
Good spontaneous respiratory

NO

99%

On O2 inhalation

On assist/ controlled mechanical

ventilation/ resuscitator bag

Other details

YES
Dentures, prosthetic, nail polish
removed

NO

Jewelry, patient property endorsed

Hospital gown on

Bowel prep

Sand bag

Use of special equipment

Contraptions on the PT

YES
w/ peripheral IV line/ w/ Heploch IV
Catheter

Nasogastric/ Orogastric tube (NGT

or OGT)
Indwelling folley/ condom catheter

Jackson Pratt drain/ any drain

Chest tube (s)

NO

Mediastinal tube

Nephrostomy tube

IABP (intra-aortic balloon)

Pacemaker / Pulse generator

ECG/ Pulse oximetry monitoring

Invasive arterial BP monitoring

Central line/ PA line/ peripheral line

Special precautions

YES

NO

Infection
Implant
PWD/ Mentally unstable
Limb precaution R-arm-L R-leg-L

Fall precaution (moderate to high)

Other precautions

Documentations required

YES

NO

Consent anaesthesia

Procedure

Surgery

Blood Transfer

Refusal waiver for Procedure/

Surgery

Risk Assessment form

YES
Anaesthesia evaluation

Cardiac evaluation

NO

Pulmonary

Renal

Y085 Malacaste, Elaine Jadena

Bday: 12/28/78
; Age:37

Admission date: March 5, 2016

Preoperative diagnosis
G4 P3 (3003) Pregnancy uterins 35 weeks age of gestation, cephalic,
not in preterm labor
Thalassemia
Chronic hypertensive vascular disease with superimposed preecclampsia, w/ severe features
Partial HELLP syndrome
Impending edema
Operation done
Primary low transverse caesarean section under spinal anaesthesia
Post-op diagnosis
G4P4 (3104) pregnancy uterine 34-35 weeks, LOT, delivered via LTCS
to a live baby girl BW 1.49kg, BL 41cm; AS 8.9 SGA, symmetric chronic
hypertensive vascular disease w/ superimposed pre-ecclampsia, w/
severe feature, Thalassemia
Operative time: Start 9:05PM
End 11:00PM
Immediate post-operative condition: stable
Operative record:
IE under anaesthesia:cervix soft, tcm dilated, (+) BOW, cephalic,
floating on opening, the lower uterine segment was formed. Proceeded
w/ low transverse caesarean section. The amniotic fluid was clear and
adequate. Delivered to a liveBBG, LOT, BW 1.49kg; BL 41cm AS 8.9
SGA, symmetric MT 34-35 weeks. Placenta was manually and
completely extracted from its posterior implantation. Cotyledon and
membranes were complete, infarcts noted. The uterus was well
contracted upon closure. Both fallopian tubes and ovaries were grossly
normal.
Estimated blood loss: 600mL