DYSTOXIA / FETAL DISTRESS

CASE PRESENTATION

PATIENTS PROFILE
Name: C.R. Age: 30y/o Religion: Catholic Medical Dx: G1P1 Post-Op LTCS secondary to arrest in cervical dilatation Chief Complaint: Hypogastric Pain Date of Admission: 12/10/11

PATIENTS HISTORY
Present OB-Gyne History: G1P1 (1001) 39 1/7 weeks Cephalic LTCS secondary to Arrest in Cervical Dilatation with Full live term Baby Girl 6lbs, 47cm. Past OB-Gyne History G1P0 39 1/7 weeks, Cephalic in labor arrest in cervical dilatation Family Hx: (+) Hypertension - Mother, (+) Diabetes Mellitus - Mother

POST PARTUM ASSESSMENT

V/S: T: 36.2 P: 74 R: 20 BP: 110/70 Height: 52 Weight: Not assessed. General Appearance: Patients posture is not fully erect while sitting and standing due to pain; Client still have difficulty in ambulating; Patient is clean and has no odor. Client is conscious and cooperative during the assessment; Speech is understandable. Abdomen: Clients abdomen was globular in shape; there is presence of bandage due to the clients surgical incision and she still feels pain when moving; there is also presence of linea nigra. Other details werent assessed. Other information about the assessment are normal.

DIAGNOSTIC EXAM
Hematology Result: ACTUAL RESULTS
RBC: 4.0 6.0 x 10^12/L HGB: 120 180 g/L HCT: 0.370 0.540 Segmenters: 50 70 % Lymphocytes: 20 44 %

NORMAL RESULTS
RBC: 3.65 HGB: 108 HCT: 0.328 Segmenters: 81 Lymphocytes: 11

MEDICATIONS
Generic Name: Hyoscine Classification: Antispasmodics / Muscle Relaxants Indication/s: Genitourinary spasm Dose/Route: 1amp/IVT Frequency: Q2 x 2doses

MEDICATIONS
Generic Name: Cefuroxime (Cephalosporins Second Generation) Brand Name: Zegen Classification: Therapeutic: anti-infectives Indication/s: Treatment of urinary tract and gynecologic infection Dose/Route: 750mg/IVT Frequency: Every 12 hours (Q12) Changed to Every 8 hours (Q8)

MEDICATIONS
Generic Name: Pethidine Brand Name: Demerol Classification: Class of Phenylpiperidine Derivative Opioids Indication/s: Relief of moderate to severe pain, pre-op medication, support of anesth & obstet analgesia. Dose/Route: 25mg/IVT Frequency: Every 4 Hours (Q4)

MEDICATIONS
Generic Name: Mefenamic Acid Brand Name: Dolfenal Classification: Nonsteroidal AntiInflammatory Drugs (NSAIDs) Indication/s: Symptomatic relief of mild to moderately severe pain Dose/Route: 50mg Tab Frequency: PRN for Stomach Pain