Last Name: Shepherd First Name: Meredith M.

I: Grey Gender: Female

Address: Bakakeng, Baguio City Religion: Catholic Age: 31
Contact No.: 09151234876 Ethnicity: Filipino
Occupation/Profession: Housewife
Emergency Contact: Derek Shepherd Relationship: Husband Contact No.: 0912348765
OB Score: G1P1 Blood Type: O
Admitting Physician: Dr. Montgomery
Hospital: Benguet General Hospital

University of the Cordilleras

College of Nursing
1st Semester SY 2020-2021

DR/NR/LR VIRTUAL DUTY

Date of Admission: September 8, 2021

PATIENT PROFILE

Admitting Diagnosis: GIP1, 36 weeks AOG

Final Diagnosis: GIP1 Pregnancy uterine, cephalic, delivered to live baby boy 2.94 kg by NSD with episiotomy

Mrs. Shepherd was admitted on the OB-ward on September 8, 2021 in the evening. She complained of frequent contractions.
Prior to admission the husband stated that Mrs. Shepherd is in good condition wherein she can cook, and do light household
choirs but the pain felt persist that's why her husband decided to go to the hospital with his wife.

7:30 am of September 9, 2021 the patient was brought in the labor room from the OB-ward accompanied by student nurses on
duty from the University of the Cordilleras. She is on her 36 weeks AOG, and with ongoing IVF of D5LRS 500mL with 250 ml
level remaining, infusing well at the right metacarpal vein and upon: Internal examination done by Dr. Liteng, she has a cervical
dilation of 6-7 cm. In the labor room, the mother is observed to be irritated; in squatting position; "Sobrang sakit. Hindi ko
maexplain yung sakit. Parang hindi ko na kaya. First baby ko pa naman to" as verbalized, the mother appears with facial
grimace. Her membranes were intact. Mrs. Shepherd temperature is 36.7. pulse of 85 bpm and respiration of 20 bpm and her
blood pressure was 100/70. The fetal heart tones were 134 and regular.

The mother enters the delivery room at exactly 11:30 am, in full cervical dilation and continuous uterine contractions. Oxytocin
were injected to her right deltoid with initial BP of 100/80. The physician also administers lidocaine and perform right
mediolateral episiotomy. The mother successfully delivers a health baby boy via NSD, 11:46 am with a weight of 2.94kg;
length of 48cms; HC of 33cms; CC of 32 cms; Abdomen circumference of 29 cms; and arm circumference of 12 cms; with 1
loose cord loop, meconium stain; loud cry heard; appears pinkish and with thick vernix caseosa especially on the neck area. The
placenta was also delivered, 11:50 am. The vital signs of the mother before PO are as follows BP= 120/80; PR= 89 bpm; RR=
21bpm and temperature of 36.4.

Evacuation of blood fragment were done by the physician manually and some of the uterine specimen is subjected to biopsy.

Immediate newborn care was done. The baby has a good latching and sucking reflex. The mother and baby were transferred
from recovery to OB ward accompanied by student nurse on duty.