UNIVERSITY OF SANTO TOMAS College of Nursing Obstetric Nursing Case Presentation

Name:

DEMOGRAPHIC DATA: Name: P.G., 33 y/o Date of Birth: July 13, 1978 Address: 75 Apple St., Paranaque City Occupation: Telemarketer Nationality: Filipino Civil Status: 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 a live 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.

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.

prebreakfast,- 18 u, predinner- 10u, Humalog premeal- 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 doesn t have any allergic reactions. She did

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

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

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

and gave birth last January 6, 2012 by CS. She and her partner use withdrawal family planning method. Prenatal Checkups 1 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. 2
nd st

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 didn t 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

PNCU at private OB in Paranaque: Congenital

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.

anomaly requested but done only at 8 mos AOG (December 3, 2011). Single, live, intrauterine pregnancy in breech presentation 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

They lived in together for three years and had a baby boy. Their relationship didn t work out. They broke up. After 2 years she met another guy but like her first relationship, it didn t 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 didn t 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. She s 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 doesn t 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 didn t have a communication with her him. Patient s support comes from her mother who s with her all throughout her pregnancy and her hospitalizations.

3rd PNCY UST OB 1st PNCU with a BP of 160/100 CBC (12/16): Hgb 9.0, hct 0.29, WBC 11.1, plt adeq, 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 about 28-29 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, Plt 22.5, N74 L26 CBC (12/22) Hgb 95, Hct 0.27, Plt 22.5, N74 L28.

REVIEW OF SYSTEMS

On Admission: BP: 180/100 PR: 90 RR: 19 Temperature: 36.9 oC 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 5 LICS MCL regular rate and rhythm with no heart murmurs Abdomen: globular, FHT 140, no uterine contractions, External Genitalia: (=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 Neurologic Exam: Conscious coherent oriented to person place and time, can follow commands Cranial nerves: intact cranial nerves Motor: no weakness, MMT 5/5 on all extremities Sensory: No sensory deficits Reflexes: superficial, deep tendon normal.
th

On Interview: 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 Negative for colds, cough and Clear breath sounds upon Symmetrical chest expansion. chest pain. dyspnea. auscultation.

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 Homan s 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- homan s sign absent E- independent, eager to see and take care of infant, no signs of depression

Past Medical History: y Chickenpox Highschool nd y (+) DM since 2 pregnancy (1995) maintained on metformin 500mg/tab 1 tab BID. On insulin since November 2010 y S/P CS - 1999: 3rd baby y (+) 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/p panretinal photocoagulation OS (October 2010) Binan Doctors Hospital y (-) Allergy, Asthma, PTB, Thyroid Disease

Family History: y (+) DM maternal grandmother and parents y (+) HPN parents y (+) Cancer - grandfather y (-) Allergy, Asthma, PTB, Thyroid Disease, CV disease

Social History: y Non-smoker y Occasional alcoholic beverage drinker y Denies use of illicit drugs

Sexual History: y The patient s first sexual contact happened when she was 21 years old with her lpm sexual partner. y (-)post-coital bleeding y (-)dyspareunia y They didn t use any family planning method. They used withdrawal most of the times.

Menstrual History: y Menarche: 13 years old y Interval: 28-30 days y Duration: 5-7 days y Amount: 3 pads/day, fully soaked y Symptoms: no dysmenorrhea y LMP: Aug 15, 2010 y PMP: unrecalled y AOG: 22-23 weeks by LMP

Obstetrical History: Gravida Year Mode of Delivery 1 1991 Outlet Forceps Extraction

Baby y Female, Full term y Birth weight: 9Lbs

1995

NSD

y Male, Full term y (+) dystocia 2 to macrosomia y died 1 day after delivery

NURSING HISTORY
Patterns of Functioning: Based on Gordon s Typology of 11 Functional Health Patterns, reflected in Kozier and Erb s Fundamentals of th Nursing (8 edition)

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 5 2 , and presently weighs 123 pounds (taken February 2, 2011). Elimination pattern. (Describes the patterns of excretory function: bowel and bladder) Prior to morbidity, the patient moves her bowels every day, usually in the morning. She usually had brownish, formed stools, 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 and cognitive 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 in function, 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 patient s 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 her episodes 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 sa sakit ng tiyan ko. During these episodes, her husband gently strokes her abdomen; hinihimas ko nalang hanggang sa makatulog na siya sa sakit as verbalized. Self-perception/ self-concept pattern. (Describes the client s selfconcept pattern and perceptions of self) When asked on how she sees herself, the patient responded ganoon parin, walang nagbago nagkasakit lang. 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 and tired, apparently with tears swelling up in her eyes which she gently pats dry. The patient s husband describes her as a jolly, thoughtful person who enjoys long chats and insightful conversations. He now describes her as tumamlay, at humina magsalita. Role-relationship pattern. (Describes the client s pattern of role participation and relationships) 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

Health-perception/ health-management pattern. (Describes the client s perceived pattern of health and well-being and how health is managed) 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 nasanay na. 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 patient s husband verbalized oo naman kung kailangan at doon gagaling, except if hindi kaya financially. Activity-exercise pattern. (Describes the pattern of exercise, activity, leisure and recreation) 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 sleep, rest, and relaxation) 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 na makatulog." 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. her husband is the one who helped her when doing some activities. Nutritional-metabolic pattern. (Describes the client s pattern of food and fluid consumption relative to metabolic need and pattern indicators of nutrient supply) th Prior to her 4 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. nd By 2 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 and described as konti lang. 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 malaki talaga ang 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

relationship with her husband, described as maganda ang relasyon namin. May mga tampuhan man, pero normal naman iyon. Maganda ang 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-sari store. But with her present state, she is not able to perform her responsibilities. Sexuality-reproductive pattern. (Describes the client s patterns of sexual and productive 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 ligation after the birth of their 4th child.

Coping/ stress-tolerance pattern. (Describes the client s general coping pattern and the effectiveness of the pattern in terms of stress 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 in a compound with her relatives helps in her management of problems. Value-belief pattern. (Describes the patterns of values, beliefs, and goals that direct the client s choices and decisions) 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 patient s family attends mass as a group regularly. Her goal at present, as quoted, siyempre, dapat gumaling.

COURSE IN THE WARD

DATE January 3, 2012 FOCUS Admission, high blood pressure, Anemia Elevated levels of BUN, BUA, creatinine and LDH Albuminuria, hematuria Glycemic control Mixed vaginal infection MANAGEMENT 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 buttock Requested for: y CBG with platelet count y Uric Acid y BUN, creatinine y SGPT, SGOT y Lactose dehydrogenase, Blood uric acid y 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 Patient s 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 8 Predinner 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:

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 DTR s ++ 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: 30 Pre 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/IV y 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 water High 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 nd Facilitated transfer of 2 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 site Still with Morphine precautions Gave Tramadol 50 mg/SIVP q8 PRN For open dressing the morning after. Prepared materials at bedside Encouraged ambulation Gave Pre BT meds: y Paracetamol 500 mg/tab 1 tab y Diphenhydramine 50 mg/cap 1 cap Continued Nicardipine drip to follow 10 mg in 90 cc D5W to run @ 40 gtts/min to

Jan 8

Input:2465 ml; Urine Output: 43cc/hr

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 <30 cc/shift Referred if BP > 160/100mmHg Discontinued oxytocin containing IVF Hooked to 1L D5NSS @ 20 gtts/min Shifted 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, headache Prob 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 ++ BP range 140-190/100; 120130/80-90 Clear breath sounds Well contracted uterus Normal lochia DTR s +++ (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

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

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 platelet y SGPT, SGOT y 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 NPO Facilitated 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

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 @ 120130/70-80 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 HGB RBC HCT MCV MCH MCHC RDW MPV PLATELET WBC DIFFERENTIAL COUNT NEUTROPHILS METAMYELOCYTES BANDS SEGMENTERS LYMPHOCYTES MONOCYTES EOSINOPHILS BASOPHILS 89 (LOW) 2.89 (LOW) 0.26 (LOW) 90.60 30.90 34.10 13.90 8.70 200 9.80 0.70 0.70 0.30 g/l X 10 ^12/L U^3 Pg g/Dl fL X10^9/L X10^9/L

BANDS SEGMENTERS LYMPHOCYTES MONOCYTES EOSINOPHILS BASOPHILS Reference Range 120-170 4.0-6.0 0.37-0.54 87 5 29 2 34 2 11.6-14.6 7.4-10.4 150-450 4.5 10.0 0.50 0.70 0.00 0.50 0.20 0.00 0.00 0.00 0.05 0.70 0. 40 0.07 0.05 0.01

0.88 0.12 -

0.00 0.50 0.20 0.00 0.00 0.00

0.05 0.70 0. 40 0.07 0.05 0.01

Complete Blood Count: January 06, 2012 (USTH) Complete Blood Result Unit Count HGB 78 g/l RBC 2.44 X 10 ^12/L HCT 0.22 MCV 90.90 U^3 MCH 31.90 Pg MCHC 35.10 g/Dl RDW 14.30 MPV 8.10 fL PLATELET 179 X10^9/L WBC 22.60 X10^9/L DIFFERENTIAL COUNT NEUTROPHILS 0.90 METAMYELOCYTES BANDS SEGMENTERS 0.90 LYMPHOCYTES 0.10 MONOCYTES EOSINOPHILS BASOPHILS -

Reference Range 120-170 4.0-6.0 0.37-0.54 87 5 29 2 34 2 11.6-14.6 7.4-10.4 150-450 4.5 10.0

0.50 0.70 0.00 0.50 0.20 0.00 0.00 0.00 0.05 0.70 0. 40 0.07 0.05 0.01

Complete Blood Count: January 05, 2012 (USTH) Complete Blood Result Unit Count HGB 110 g/l RBC 3.53 X 10 ^12/L HCT 0.32 MCV 90.00 U^3 MCH 31.30 Pg MCHC 34.80 g/Dl RDW 13.80 MPV 8.70 fL PLATELET 209 X10^9/L WBC 11.7 X10^9/L DIFFERENTIAL COUNT NEUTROPHILS 0.88 METAMYELOCYTES -

Reference Range 120-170 4.0-6.0 0.37-0.54 87 5 29 2 34 2 11.6-14.6 7.4-10.4 150-450 4.5 10.0

0.50 0.70

Complete Blood Count: January 08, 2012 (USTH) Complete Blood Result Unit Count HGB 126 g/l RBC 3.99 X 10 ^12/L HCT 0.36 MCV 89.50 U^3 MCH 31.50 Pg MCHC 35.20 g/Dl RDW 13.80 MPV 8.10 fL PLATELET 228 X10^9/L WBC 25.00 X10^9/L DIFFERENTIAL COUNT NEUTROPHILS 0.93 METAMYELOCYTES -

Reference Range 120-170 4.0-6.0 0.37-0.54 87 5 29 2 34 2 11.6-14.6 7.4-10.4 150-450 4.5 10.0

0.50 0.70

BANDS SEGMENTERS LYMPHOCYTES MONOCYTES EOSINOPHILS BASOPHILS

0.93 0.07 -

0.00 0.50 0.20 0.00 0.00 0.00

0.05 0.70 0. 40 0.07 0.05 0.01

1/11/2012

12AM

222mg/dL

RELAYED; Given Humulin R, 1 unit given per SC

Complete Blood Count: January 10, 2012 (USTH) Complete Blood Result Unit Count HGB 111 g/l RBC 3.51 X 10 ^12/L HCT 0.31 MCV 88.80 U^3 MCH 31.60 Pg MCHC 35.60 g/Dl RDW 13.70 MPV 8.50 fL PLATELET 140 X10^9/L WBC 14.70 X10^9/L DIFFERENTIAL COUNT NEUTROPHILS 0.89 METAMYELOCYTES BANDS SEGMENTERS 0.89 LYMPHOCYTES 0.11 MONOCYTES EOSINOPHILS BASOPHILS -

6AM
Reference Range 120-170 4.0-6.0 0.37-0.54 87 5 29 2 34 2 11.6-14.6 7.4-10.4 150-450 4.5 10.0

190mg/dL

Blood Chemistry: January 03, 2012 (USTH) Result Unit Urea Nitrogen Blood uric Acid Creatinine SGOT SGPT LDH Sodium Potassium Complement Factor 3 Ionized Calcium Amylase Lipase Magnesium 36.15 9.92 1.52 20.15 14.85 274.59 137.0 4.75 mmol/L mmol/L g/L mmol/L u/L u/L mg/dL mg/dL mg/dL mg/dL

Reference Range 9-23 2.7 7.3 0.5 1.2 0 32 0 31 100 190 137 147 3.8 5 0.9 1.8 1.12 1.32 10 130 13 60 4-7 mg/dL

0.50 0.70 0.00 0.05 0.50 0.70 0.20 0. 40 0.00 0.07 0.00 0.05 0.00 0.01

Complete Blood Glucose Monitoring

Date 1/7/2012

Time 10AM 3PM 10PM

Result 84mg/dL 68mg/dL 73mg/dL 98mg/dL 120mg/dL 147mg/dL 149mg/dL 142mg/dL 207mg/dL 129mg/dL 139mg/dL

Action

Blood Chemistry: January 05, 2012 (USTH) Result Unit Urea Nitrogen Blood uric Acid Creatinine SGOT SGPT LDH Sodium Potassium Complement Factor 3 Ionized Calcium Amylase Lipase Magnesium 0.56 1.28 mg/dL mg/dL mg/dL

Reference Range 9-23 2.7 7.3 0.5 1.2 0 32 0 31 100 190

1/8/2012

6AM 2PM 10PM

RELAYED

374.00 mmol/L mmol/L g/L mmol/L u/L u/L mg/dL

137 147 3.8 5 0.9 1.8 1.12 1.32 10 130 13 60 4-7 mg/dL

1/9/2012

6AM 2PM 9PM

RELAYED RELAYED

Blood Chemistry: January 08, 2012 (USTH) Result Unit Urea Nitrogen Blood uric Acid Creatinine SGOT SGPT LDH Sodium Potassium Complement Factor 3 Ionized Calcium 1.03 mg/dL mg/dL mg/dL

1/10/2012

2p BF 2 p Lunch CBG q4 while on NPO 6PM 10PM

Reference Range 9-23 2.7 7.3 0.5 1.2 0 32 0 31 100 190 137 147 3.8 5 0.9 1.8 1.12 1.32

173mg/dL CBG q6

141.0 4.04

mmol/L mmol/L g/L mmol/L

Amylase Lipase Magnesium

u/L u/L mg/dL

10 130 13 60 4-7 mg/dL

Blood Chemistry: January 10, 2012 (USTH) Result Unit Urea Nitrogen Blood uric Acid Creatinine SGOT SGPT LDH Sodium Potassium Complement Factor 3 Ionized Calcium Amylase Lipase Magnesium mg/dL mg/dL mg/dL

5.59 0.87 71.41

Reference Range 9-23 2.7 7.3 0.5 1.2 0 32 0 31

mmol/L mmol/L g/L 1.03 130.13 15.36 5.76 mmol/L u/L u/L mg/dL

100 190 137 147 3.8 5 0.9 1.8 1.12 1.32 10 130 13 60 4-7 mg/dL

Sugar Leukocytes Erythrocytes Bilirubin Nitrates Ketones Urobilinogen RBC Pus cells Hyaline cast Transitional Epithelial Cell Squamous Cell Renal Cell Bacteria

Negative Negative Positive Negative Negative Negative Normal 2-4/hpf 0-2/hpf

FEW FEW FEW

Blood Typing: January 06 & 07, 2012 ABO Blood Group and Rh factor A POSITIVE

Coagulation Assay: Januray 06, 2012 Results Prothrombin Time 10.8 secs Normal control 12.0 secs Prothrombin Ratio International Normalized Ratio Activated PTT Normal control 0.9 0.9 32.0 secs 33.5 secs

Reference Range 10.3 14.1 secs

0.8 1.3 27.0- 45.4

Urinalysis: January 3, 2012 Results Color Light yellow Transparency Slightly turbid pH 6.0 Specific gravity 1.020 Albumiin ++ Sugar Negative Leukocytes 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 seen Urinalysis: January 5, 2012 Color Transparency pH Specific gravity Albumin Results Light yellow Slightly turbid 7.0 1.010 +++

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 Presentation BPD HC AC FL Average AOG Fetal Cord Vessels FHR Sex Placenta Amniotic fluid SEFW FAC Single Breech (Floating) 8.07 --5.66 30-31 weeks 2 Arteries: 1 Vein 126 bpm NOT INCLUDED Anterior, Grade II 14.22 1406grams 24.31 cm

Follow-up chest X-Rayfew hours now shows 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 sheet

Conclusion: Mild Flare

ULTRASOUND REPORT: January 10, 2012

-

A Biophysical scoring was done and it reports that: Amniotic Fluid Body Movement Fetal Tone Fetal Breathing Total 2/2 2/2 2/2 2/2 8/8 -

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 in diameter 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 1.7 cm 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 accumulation in the perirenal region. Spleen is not enlarged. Negative for intrasplenic mass. Incidentally, minimal pleural effusion on the right is noted. Minimal pericardial fluid likewise seen. Echopattern of both kidneys are diffuse.

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 Rhythm Chest 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

Impression: Hepatic cyst, Segment VI. Normal sized gallbladder with bile sludge. Non-specific enlargement of the pancreatic head with non-dilated pancreatic ducts. 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.

STAT orders MEDICATIONS 1/3/12 Date 1/3/12 Medications Hydrocortisone 60mg/IV Prednisone 30mg/tab afterbfast Humulin N 14 units/SC pre bfast Humulin N 10 units/SC pre bfast Humalog 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 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

1/6/12

Tramadol 50mg/IV PRN x pain score >4 q8 Metoclopramide 10mg/Isive PRN q8 Diphenhydramine 50mg/IV PRN pruritus Dolcet tab q8 Hydrocortisone 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 pre bfast 6am Metoprolol 100mg/tab BID 6am,6pm Ranitidine 50mg/IV 2am,2pm HAA 100mg/IV q12 3am,3pm Ampicillin 500mg/IV q8