Profile of Patient:

Age: 32
Marital Status: Married
Occupation: Nurse
Blood Type: AB
Wt: 68kg; Ht: 156cm
LMP: 6/27/2020
Room No.: WW 309
Hosp. No.: 08-51-52

Medications for Pharmacologic Study

 Nifedipine 10mg SL NOW; 2/21/2021 - Nifedipine 10mg tab TID
 Hydrazaline Drip: 40mg in 250cc of D5W regulated at 16cc/hr initially
 MgSO4 IVTT now then 5gm IM on each buttock (10mg total) then 5gm on
alternating buttock q4H
 Dexamethasone 6mg IM now on deltoid then q12H
 Coamoxiclav 600mg IVTT q8H
 Tramadol Drip: PNSS 1L + 200mg tramadol to run for 24hrs x 2 cycles
 Diphenhydramine 50mg IVTT q8H PRN for allergic reactions

Hx:
First child was delivered prematurely through “E” CS at 35 weeks AOG via “E” CS
Had 2 spontaneous abortion on 2nd and 3rd pregnancy
Night PTA - Headache with PRS of 8/10
Morning PTA - H/A is more severe, assoc with diplopia with PRS of 10/10

Doctor’s Order Problem: Elevated BP and Diplopia

CC: H/A and Diplopia

Labs:
2/21/2021
Hgb - 123 g/L; Hct - 0.38

Possible NCP:
 Acute Pain (tungod headache)
 Risk for Injury (tungod diplopia)
 Elevated Body Temp (temp upon admission 37.6°C)
 Elevated Blood Pressure (due to pre - eclampsia and may maintenance drug hiya)

Doctor’s Order:
2/21/2021 @ 5:45AM
VS:
T= 37.6°C
HR= 110bpm
RR= 24cpm
BP= 190/110mmHg
O2 Sat= 98%

CBG= 105mg%
 Admit to room under service
 Secure consent for admission and mgt
 TPR & BP q1H until stable
 NPO tempo
 Facilitate lab and diagnostics exams as ordered
 Start venoclysis with D5NM 1L @ 20gtts/min
 Meds:
 Nifedipine 10mg SL NOW
 Hydrazaline Drip: 40mg in 250cc of D5W regulated at 16cc/hr initially
 MgSO4 IVTT now then 5gm IM on each buttock (10mg total) then 5gm on
alternating buttock q4H
 Dexamethasone 6mg IM now on deltoid then q12H
 Insert FBC Fr 16 and attach to urobag
 CBR without TP (complete bed rest w/o toilet privileges)
 Monitor FHT q1H temporarily
 Check deep tendon reflexes q1H
 Left lateral decubitus please
 O2 inhalation @ 3LPM
 Strict I&O monitoring
 Refer for untoward manifestations
 Refer accordingly

2/20/21 @ 11:00AM
BP= 190/100mmHg
Drip at 26cc/hr
Pain scale of H/A (headache) 7/10
(+) diplopia

Labs:
 Cranial CT Scan, Plain: Normal Findings
 12 Lead ECG: Sinus Tachycardia, Normal Axis, No Ischemic Changes
 Transabdominal UTZ: single live intrauterine pregnancy c AOG of 33 2/7weeks
c BPS of 8/8, no fetal abnormalities noted; female fetus c FHB= 145bpm
 CBC: medyo diri ko clear sorryy :(((
 SGPT: 62.2 U/L
 SGOT: 58.4 U/L
 Creat: 116umol/L
 BUN: 4.5mmol/L Normal
 BUA: 385.2umol/L Normal
 NA: 138.4mmol/L Normal
 K: 3.85mmol/L Normal
 CA: 1.91mmol/L Normal

2/20/21 @ 10:00PM
BP= 160/110mmHg
Bb. Girl Out= 8:45PM
Placenta Out= 8:50PM
AS - 7, 8 Thinly MS
BW= 1.9kg
BL= 42cm
33 weeks AOG by BS
Blood Loss = 600cc

Post - Op Orders
 To RR (recover room)
 IVT TF:
 PLR 1L x 8hrs
 D5LR 1L x 8hrs
 D5NM 1L x 8hrs
 Maintain hydrazaline drip @ 46cc/he
 Meds:
 Coamoxiclav 600mh IVTT q8H
 Tramadol Drip: PNSS 1L + 200mg tramadol to run for 24hrs x 2 cycles
 Diphenhydramine 50mg IVTT q8H PRN for allergic reactions
 Nifedipine 10mg tab SL NOW
 D/C MgSO4 infection
 Continue monitoring
ADD:
 Transfuse 2nd unit of blood
 Watch out for fvr, transfusion reaction
 Repeat Hgb and Hct in AM (morning)
 Refer accordingly

2/21/2021 @ 9:30AM
BP= 150/90mmHg
(+) Flatus
(+) BM
(-) Complaint

Labs: Hgb - 123 g/L; Hct - 0.38

 May have clear liquids (search nala kun ano it clear liquids) NOW then general
liquids (search nala kun ano it general liquids) this evening
 Hydralazine drip to consume
 Nifedipine 10mg tab TID
 Decrease BP monitoring to q6H
 Refer accordingly

2/22/2021 @ 8:00AM
BP Range= 130/70mmHg - 140/100mmHg
(+) BM, 2x
(-) Complaint
 May have soft diet
 IVT TF: D5NM 1L @ 20gtts/min
 Cont. Meds
 Refer accordingly

2/23/2021 @ 8:45AM
BP = 180/90mmHg
(-) Complaint
(-) Vaginal D/C
 Full low salt, high calcium diet
 IVF to consume then terminate
 Shift Coamoxiclav IV to PO 625mg TAB BID x 4 days more
 Mefenamic Acid 500mg CAP TID x 5 days
 For dressing in AM, please prepare the following:
 Dressing tray
 Op - site dressing
 Sterile gloves 7.0
 For possible discharge
 Please estimate bill until tomorrow
 Refer accordingly

2/24/2021 @ 7:45AM
BP= 130/70mmHg
(-) complaint
Well, Coaptated Wound with No Discharges\
 MGH
 Home Meds:
 Nifedipine 10mg tab TID
 Coamoxiclav 10mg tab BID x 3 days more
 Mefenamic Acid 500mg CAP TID x 4 days more
 Daily wound dressing
 Follow - up at OPD 1 week or earlier if with problems
 Advised