May 8-9

May 8-9, 2023
Urinalysis:
OB Physiologic: 1 RBC: 8
OB Pathologic: 1 WBC: 1
OB Operative: 1 EC: 1
OB medical: 1 Bacteria: 57
OB Physiologic: 1
TURCOLAN, SHIDOMAE Plans:
39years old For transfer to recovery room
Gravida 6 Para 6 (6006) Pregnancy For post-partum care and monitoring
uterine term, cephalic delivered Continue postnatal medications
spontaneously to a live baby boy with Vitamin C + Zinc 1 tab BID
Apgar Score 8,9 Ballard Score 37 weeks Ferrous sulfate BID
birthweight 2650g appropriate for Calcium + Vitamin D3 BID
gestational age Keep uterus well contracted
Grandmultipara Advised exclusive breastfeeding
Advanced maternal age We will watch out for profuse vaginal
bleeding, abdominal pain, fever or
s/p normal spontaneous delivery with dyspnea
perineal support (March 28, 2023) FP: DMPA while awaiting BTL

Currently, patient has well contracted OB Pathologic: 1
uterus with minimal lochial discharge JIMENEZ, CRISTEL
and is at the recovery room 16 years old
Gravida 1 Para 1 (1001) Pregnancy
Baby is at bedside with good cry and uterine term, cephalic delivered
activity spontaneously to a live baby boy with
Apgar Score 8,9 Ballard Score 37 weeks
With normal and stable vital signs birthweight 2650g appropriate for
gestational age
On internal examination, vagina admits 2 Gestational diabetes mellitus, unknown
fingers with ease, cervix admits 2 control
fingers, corpus enlarged to 3 months size To consider asymptomatic bacteriuria
with well contracted uterus Anemia mild
Teenage pregnancy
EBL 400
s/p normal spontaneous delivery with
CBC right mediolateral episiotomy and repair
Hgb: 11.0 under local anesthesia with post
Hct: 0.34 placental IUD insertion (March 28,
WBC: 9.6 2023)
PC: 301
Currently, patient has well contracted For referral to pedia for possible
uterus with minimal lochial discharge transfusion of pRBC and initiation of
and is for transfer at the recovery room antibiotics for asymptomatic bacteriuria
For CBG monitoring premeals TIDHS
Baby is at bedside with good cry and Keep uterus well contracted
activity Advised exclusive breastfeeding
We will watch out for profuse vaginal
Vital signs: bleeding, abdominal pain, fever or
BP: 120/80 dyspnea
HR: 105-111 Long term plan: 75g OGTT 6 weeks post
RR: 18 partum
Temp: Afebrile
O2sat: 98% OB OPERATIVE: 1
GALVAN, EDNALYN
On internal examination, vagina admits 2 33 years old
fingers with ease, cervix admits 2 G3P3 (3003) PU term cephalic delivered
fingers, corpus enlarged to 3 months size operatively to a live term baby boy with
with well contracted uterus with palpable AS 8,9, BS 38 weeks, BW 2700g, AGA
IUD string Anemia, mild
Previous CS secondary to unrecalled
CBC indication (2010, Ospital ng Sampaloc)
Hgb: 10.6 and repeat (2016, Ospital ng Maynila)
Hct: 0.33
WBC: 13.1 S/p LTCS III with bilateral
PC: 449 salpingectomy under spinal anesthesia
(May 8, 2023)
Urinalysis
RBC: 92 Intraoperatively, noted gravid uterus
WBC: 14 with well-formed lower uterine segment.
EC: 0 The amniotic fluid was clear. We we
Bacteria: 47 were able to deliver to a live baby boy
Leukocytes: 2+ with good outcome. Placenta located
posterior. Both Fallopian tubes and
Plans: ovaries are grossly normal. Our
DM diet estimated total blood loss is 600cc.
For post-partum care and monitoring
Continue postnatal medications Currently, patient is at the recovery room
Vitamin C + Zinc 1 tab BID with well-contracted uterus and minimal
Ferrous sulfate BID vaginal bleeding.
Calcium + Vitamin D3 BID
Cefuroxime 500mg BID x 7 days Baby is for rooming-in.
Postoperative vital signs:

BP: 120/70mmHg To consider IUGR
HR: 82 bpm Hypokalemia
RR: 17 cpm Advanced maternal age
Temp: 36.2C
O2sat: 100% Patient is a non registered, referred case
from Caloocan city who was referred in
CBC our institution for further evaluation and
Hgb: 10.5 management.
Hct: 0.34
WBC: 6.5 Patient was cognizant of pregnancy after
PC: 259 3 months missed menses and had 3
unremarkable PNCU at St Norbert lying
Urinalysis in. She was apparently well until…
RBC: 0
WBC: 0 1 day PTC, noted temporal headache and
EC: 1 RUQ abdominal pain associated with
Bacteria: 40 post prandial vomiting. She immediately
sought consult at St Norbert Lying in
Plan: where she was advised to transfer to
For postpartum care and monitoring tertiary hospital due to elevated BP of
For diet progression once at the wards 200/120mmHg. No medication was
Continue postnatal medications given
Pain meds c/o anesthesia
Keep uterus well contracted She then consulted at CCMC, work up
Apply and maintain tight abdominal was done where she was diagnosed with
binder Partial HELLP and advised to transfer in
Encouraged exclusive breastfeeding our institution. Hydralazine was maxed
Advised early ambulation and deep out, MgSO4 loading dose of 4g and 1
breathing exercises dose of dexamethasone was given. She
For removal of IFC once at the wards was referred in our institution due to
For change of dressing on post-operative uncontrolled BP.
day 2
We will watch out for profuse vaginal Currently, patient is awake, alert, no
bleeding, uterine atony, derangement in blurring of vision, no headache, no,
vital signs. tachycardia episode, no vaginal bleeding,
no hypogastric pain.
OB MEDICAL: 1
GAÑA, JENELYN NAPA LMP: October 13, 2022
35 years old PMP: September 2022
Gravida 2 Para 0 (0010) Pregnancy
uterine 29 4/7 weeks AOG by LMP With vital signs
Preeclampsia with severe features BP range: 160-200/80-110mmHg
Complete HELLP syndrome Current BP 150/100mmHg
HR 92 EC: 0
RR 20 Bacteria: 128
T 36.8 Protein: 3+
O2 99%
Crea: 74.4
Anicteric sclera, pink palpebral Na: 132
conjunctiva K: 3.4
Adynamic precordium, normal rate
regular rhythm Biometry (May 8, 2023 OB SONO)
Symmetric chest expansion, clear breath SLIUP cephalic 28 weeks AOG
sounds Posterior placenta, grade II, high lying
With bipedal edema grade 1 AFI adequate (5.05cm)
Doppler velocimetry show poor
FHT 140s uteroplacental and placento-fetal blood
FH: 21 flow at the time of examination
EFW palm: 1500g Estimated fetal weight of 1023g
EFW Johnsons rule: 1395g
IE: cervix is soft and closed with no Plan:
vaginal bleeding LSLF diet
IVF: D5LR 1L x KVO
Review of ancillaries: Labs:
Serial monitoring of SGPT, LDH, CBC
Hbsag and RPR: Non reactive Still for ECG, LDH
For coordination of BPS with fetal
Labs done at CCMC (May 8, 2023) biometry at our ultrasound section
Meds:
SGOT: 233 (H) - Start Magnesium Sulfate Drip 10g in
SGPT: 148 (H) 1L PNSS to run for 100cc/hour to
BUN: 5.2 complete for 24 hours
Crea: 84 - Standby Hydralazine 5mg SIVP for BP
>/= 160/110 mmHg (maxed out)
Labs done today at the ER (May 8, 2023) - Methyldopa 250mg 2 tabs every 4
CBC hours
Hgb: 16.1 - Nifedipine 30mg GITTS OD
Hct: 0.44 - Standby Calcium gluconate 10%/IV as
WBC: 15.7 antidote for MgSO4 toxicity
PC: 86 (L) - Multivitamins 1 tab OD
- KCL tab 1 tab TID for 3 days
LDH: 1034.95 (H) For continuous CTG monitoring
For referral to Perinatology
UA For referral to IM Cardio for co-
RBC: 9 management
WBC: 3
For referral to Ophthalmology service Secure pRBC and at least 4-6 units of
for baseline fundoscopy platelet concentrates
Maintain IFC
Strict monitoring of I and O Birthplan: For primary CS 48 hours from
Continue fetal movement counting the 1st dose of steroids or anytime if with
To watch out for Magnesium Sulfate indication for delivery
toxicity (monitor UO, RR and DTR q1 Family Planning: IUD
while on MgSO4 drip)
Birthplan: For primary cesarean section Thank you very much po ma’am.
secondary to maternal indication 12
hours after dexamethasone completion
(May 10, 2023 7pm) or anytime if with
feta maternal distress
FP: IUD
Perinatology notes:
Well balanced diet with banana each
meal
IVF: Magnesium Sulfate drip 10g in 1L
PNSS to run for 100cc/hour via soluset
to complete for 24 hours
Labs:
For repeat SGPT, LDH, CBC tom am
Still for ECG, LDH
For BPS with doppler velocimetry tom
AM
Standby Hydralazine 5mg SIVP for BP
>/= 160/110 mmHg
Onima tab 1 tab TID
Dexamethasone 6mg/IM q12 to complete
4 doses
Methyldopa 250mg/tab, 2 tabs every 4
hours (4-8-12-4-8-12)
Nifedipine 30mg gitts BID (6AM and
6PM)
Start KCl tab 1 tab TID for 3 days
For continuous CTG monitoring
For referral to Ophthalmology service
for baseline fundoscopy
For referral to IM-Hem for co-mgt of
low platelet
Strict monitoring of I and O

May 8-9

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May 8-9, 2023

Postoperative vital signs:

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