Admission and discharge record

Last name cabangunay first name nympha middle name galigao wide obi dash low-risk room number
obstetrical ward address munoz poblacion 14 catbalogan city samar

Mobile number 998 5380 4306 female civil status married birthday 09 09 1987 aged 32 years 2 months
and 25 days birth place valenzuela metro manila nationality filipino religion born-again occupation
housewife admission date 12 for 2019 time 1:00 a.m. others named galigao efren feliceo

Mother: galigao nenita sales

Type of admission new philhealth dependent private employee data furnished by cabangunay joey
abalos relationship to patient spouse

Final diagnosis gravida 2 para 2 parentheses 2002 close parenthesis pregnancy uterine 38 weeks ballard
score cephalic non reassuring fetal status open parenthesis record late with decceleration minimal
variability) delivered by emergency primary low segment transverse cesarean section still alive baby boy
other diagnosis apgar 479 clear amniotic fluid baby weight 2215 g baby length 50 cm prelabor rupture of
membranous x 17 hours s/p in cesarean iud insertion colon true knot umbilical

Other operations dash procedure : emergency primary lst cs with iud insertion
Doctor’s orders

Date and time 12-4 19

G2P1(1001)

LMP 3/3/19

AOG 37 6/7 WKS

EDD 12/18/19

SOAP

s>16hrs (+) watery vaginal disxharge

o> 100/70 90 19 36.3

and grand uterus, FH 29cm

L1 breech

L2 FB at rms

L3 floating

P/e fht 140-145 bpm

E/G grossly normal

1 parous

S/E (+) eqress of MSAF

IR: cx 1 cm dil. Beginning effacemenent ceohalic

Station 2 (-) BOW

A>G2P1 ,(1001) ph 37 6/7 weeks aog cephalic

1l prom × 16hrsq

orders

 Admit under ob service

 Secure consent
 DAT
 IVF: PLR 1L FD 300CC NOW THEN 30 GTTS PER MIN
  Diagnostics cbc ph bt + rh
 Ua
 Hbsag anti td
 Hiv screening counseled
 Ampicillin 2q iv q6h ANST
 Hook to ctg monitor fhd uc queue 30 minutes then record
 Vs q4 hours 10 record
 2lr dash dr
 Refer

Date and time 12 419

Soap

 Fht:
 Ipm: cat II

Orders

 Anesthesiologist
1. First drift 300cc tlr regulate at 60 gtts per minute
2. O2 inhalation at 5 lpm
3. Maintain in left lateral decubitus position
 Prepare for possible cs
 Skin test for cefazolin
 Hook to ctg continuously for vital monitoring
 For emergency first degree cs

Date and time 12 4:19 2:15 a.m.

Soap

Fht 120 to 125

Lpm CERT III° deceleration as low as 40 bpm

Orders

For emergency first degree cs refer our anesthesiology nicu

Secure consent

Cefazolin 1 gram ivtt a n s t 10q every 8 hours

Insert foley bag catheter french 16 attach euro bag

Please facilitate travel wheel to OR

Maintain o2 inhalation left lateral decubitus position

Refer
Patient cabangunay nympha from catbalogan samar referred from s p i h

Reason for referral premature chief complaint labor pains

History of present illness 16 hours prior to admission patient noted hypogastric pain radiating to
the lower back with associated watery vaginal discharge

Past personal history negative hypertension negative negative allergies

No allergies to medications and no allergies to food

Family and social history non smoker and non alcoholic

Menstrual history menarch at age 12 duration 3 to 4 days number of pods soap per day 2 to 3 days
associated symptoms non subsequent menses interval regular duration 3 to 4 days number of
pods so per day 2 to 3 days

Obstetric history g2 p1( 1001) lmp 3-13-19 edc12 1819 aog37 6 out of 7 weeks

Pregnancy order g1

Prenatal history

Prenatal check up yes

Any illness during course of pregnancy none

Medications taken or history of admission during pregnancy ferrous sulfate

Physical examination

Patient was examined vital signs bp 100/70 heart rate 90 respiratory rate 19 temperature 36.3

Skin no active skin lesions eyes ears nose neck and throat no discharges chest and lungs
symmetric chest compressions expansions clear breath sounds cardiovascular a dynamic
precordium normal rate regular rhythm no murmur

Abdomen: fundic height : 29cm

fetal heart tone 120-125

leopolds manuever L1: BREECH L2: F13AT R MS LR:FLOATING L4:-

PELVUC EXAM

External genetalia grossly normal

Introitus porous

Speculum exam cervix relish enlarge

Internal exam cx1 cm dilation beginning effacement

Extremities full pulses

Admitting impression g2p1 1001 pu 37 6of 7 weeks aog cephalic 1 l prom x 16 hours