AFIA FRIMPOMAA,33 YEARS
G4P3AA (1 SET OF TWINS)
EGA: 37 WEEKS + 5 DAYS
EDD: 06/02/2024
REFERRAL FROM TAIFA HEALTH CENTRE OA TWIN GESTATION WITH LEADING TWIN BREECH
SCHEDULED FOR ELECTIVE CS ON TUESDAY 23/1/24
C/O: NIL
ODQ:PFM+, BPV-, LOL-, LAP-, HEADACHE-, EPIGASTRIC PAIN-, BLURRED VISION-, VOMITING-,PALPITATION-, DIZZINESS-, EASY FATIGUE+, FEVER-
O/E:
ADULT WOMAN, LOOKS WELL, NOT PALE, ANICTERIC AND AFEBRILE (36.5C). HYDRATION STATUS IS SATISFACTORY. PEDAL EDEMA TO THE LEVEL OF THE MID SHIN
VITALS:
BP: 128/74MMHG
PULSE: 95BPM
TEMP: 36.5
RR: 22CPM
SPO2: 96%ORA
FHR: 138-140BPM ; 140-144BPM
CVS: HEART SOUNDS S1 AND S2 HEARD NO MURMUR HEARD
ABDOMEN: GRAVID UTERUS MEASURING 54CM.THERE IS NO TENDERNESS AND NO OTHER PALPABLE ORGANOMEGALY.
CNS: CONSCIOUS AND ALERT
UPDATE:
BP RANGE OVER 24 HOURS HAS BEEN <140/90MMHG WITHOUT ANTI-HYPERTENSIVES.
PLAN:
– TAKE SAMPLES FOR BUE/CR, FBC AND GROUPING AND CROSSMATCHING
– DO ANESTHESIA REVIEW TOMORROW
– SECURE ONE UNIT OF BLOOD
– MONITOR VITALS 4 HOURLY
– MONITOR FHR TWICE DAILY
– ENCOURAGE ADEQUATE HYDRATION
Muntom Abrahamani
36 YRS OLD
P6
EGAW 39 + 6
post op day 5 FF TAH 2uterine rupture @ 39wks
Current medications
– tab amoxiclav 1g bd
– tab secnidazole 2g stat
-supp paracetamol 1g tds
– supp diclofenac 100mg bd
-SC clexane 40mg dly
-Vitafol 1 tab daily
-Vitamin c 100mg tds
– TAB FERROUS SULPHATE 200MG TDS
C/o: NO COMPLAINTS
ODQ: PALPITATIONS-, DIZZINESS-, HEADACHE-, VOMITING-, LAP-, BPV-, AMBULATING+, FLATUS+, STOOL+, FEVER-
ON EXAMINATION
EXAMINED AN ADULT WOMAN LYING SUPINE IN BED. PALE2+, ANICTERIC AND AFEBRILE. HYDRATION STATUS IS FAIR. NO PEDALEDEMA
VITALS
BP 109/67MMHG
P 95BPM
SPO2 96% ORA
RR: 20CPM
TEMP: 36.4
ABD:
MOVES WITH RESPIRATION, NON TENDER,NO ORGANOMEGALY, NO PALPABLE MASS
RESP: CLINICALLY CLEAR
CNS: GROSSLY INTACT
UPDATE
POST OP HB
HB 6.2(20/1/24)
PLAN
CT CURRENT MEDICATION
TO DO WOUND DRESSING
TO TRANSFUSE TWO UNIT OF BLOOD
RAHINATU SAAKA,
35 YEARS OLD
P2
POD 4 HYSTEROMY + SCRAPPING OF ADHERENT PLACENTAL TISSUE FF FAILED EOU
FINDINGS:
MODERATELY ADHERENT PLACENTAL TISSUE
WHICH WAS DETACHED AND UTERINE INCISION SUTURED
AND HEMOSTASIS SECURED. EBL 750MLS
PATIENT WAS TRANSFUSED ONE UNIT OF BLOOD AND 4 FFPS INTRA-OP
CURRENTLY ON:
– TAB AMOXICLAV 1GBD
– TAB SECNIDAZOLE 2G STAT
– SUPPPARACETAMOL 1G TDS
– SUPP DICLOFENAC 100MG BD
– SC KLEXANE 40MG DAILY
– TOTHEMA 1 VIAL BD
– NIFECARD XL 30MG DAILY
C/O: PALPITATIONS,
ODQ:
DIZZINESS-, VOMITING-, HEADACHE-,
LAP-, BPV-, DYSPNEA-, BLURRED VISION-,AMBULATING+, FLATUS+, STOOL+
OE:
EXAMINED AN ADULT WOMAN LYING SUPINE IN BED,
SHE IS PALE 3+, ANICTERIC, AFEBRILE. HYDRATION STATUS ISFAIR
VITALS:
BP: 118/68MMHG
PULSE: 81BPM
RR: 20CPM
SPO2: 96% ORA
TEMP: 36.6
ABDOMEN
ABDO WAS FULL, SOFT, NON TENDER. WOUND IS CLEAN AND DRY.
VULVA PAD LIGHTLY STAINED WITH BLOOD.
CHEST
CLINICALLY CLEAR
CVS:
PULSE REGULAR, BOUNDING, HEART SOUNDS S1 AND S2 HEARD, NO MURMUR HEARD
CNS:
CONSCIOUS AND ALERT. GCS 15/15
INVESTIGATIONS:
FBC:
HGB – 5.7 g/dL
PLT – 177.0 X 10^3/uL
WBC – 11.05 x 10^3/uL
PLAN:
– SECURE TWO MORE UNITS OF WHOLE BLOOD AND TRANSFUSE
– CONTINUE CURRENT MEDICATIONS
– MONITOR VITALS 4 HOURLY
