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Room number: 216 Age: 34 years old Gender: Female Civil status: Single Date of birth: March 24, 1978 Birthplace: Jasaan, Misamis Oriental Cultural group: Cebuano Primary Language: Bisaya Religion: Roman Catholic Highest Educational Attainment: College Graduate Occupation: Businesswoman Usual Health Care Provider: Dr. Marcella / Ob-gyne, Sonologist Reason for Health Contact: Vaginal bleeding, pale in appearance, increase abdominal girth Date of Confinement: September 3, 2012 8:54 AM Source of History: patients chart 70%, patient 30% Attending Physician: Maria Lilagri Marcella, M.D/Ob-gyne, Sonologist Impression/Final Diagnosis: Uterine Myoma, Anemia Description of Patient: PATIENT VISIT August 4, 2012 (Pre operative) Awake, coherent, sitting at the edge of the bed with patent IVF of PNSS 1L at KVO hooked at the right metacarpal vein, 800cc IV left; with complaints of vaginal bleeding 2 pads/day; pain noted at the right periumbilical area with a pain scale of 4/10. Has slender medium body built with an apparent flabby abdominal girth and a height of 50. Skin color is brown, light colors of the skin are found in palms and nails. Skin is relatively dry through the body with minimal amount of perspiration on axilla and scalp. Skin temperature is relatively warm through the body with an axillary temp.of 36.0 C. Hair in the head and body are evenly
distributed , texture is fine, short and black in color. No dandruff and lesions noted. Head is normocephalic and symmetrical; capable of facial movements like elevation of eyebrows, lowering of eyebrows, closing of eyes, able to smile, grin and frown. Facial movements symmetrical. Anicteric sclera noted, pale conjunctiva, equal chest expansion without adventitious sounds respiratory rate of 22 breaths per minute, capillary refill time of 2 seconds, pulse rate of 72 and blood pressure of 110/80 mm Hg. DAY 1 August 5, 2012 8:00 am (Pre operative) Awake, coherent @ semi fowlers position with patent IVF PNSS 1 L @ 30 gtts/min hooked at right metacarpal vein, 200 cc left; pain noted @ right periumbilical area with a pain scale of 4/10. Pallor and abdominal girth of 33.5 inches; complaints of vaginal bleeding 1 pad; V/S as follows: T=36.7, BP=110/70 mm Hg, PR=85, RR=19. 2:00 pm (Post operative) - Received awake, lying in supine position with patent IVF D5LR 500 cc @ 30 gtts/min hooked @ right metacarpal vein. Indwelling catheter noted. Pain noted @ surgical site with a pain scale of 7/10. Pallor and general weakness noted. Complaints of itchiness in the whole body, V/S as follows: T=37.4, BP=110/70, RR=21, PR=82. DAY 2 August 6, 2012 (Post operative) 8:00 am Awake, coherent @ semi fowlers position with patent IVF Bottle # 2 D5LR 1 L @ 30 gtts/min, 400 cc left hooked @ right metacarpal vein; indwelling catheter noted with 100 cc of urine, dark yellow in color; pain noted @ surgical site with a pain scale of 6/10; V/S as follows: BP=100/70, T=37.3, PR=70, RR=22. 2:00 pm Asleep in supine position with patent IVF Bottle # 3 D5NM 1 L @ 30 gtts/min hooked @ right metacarpal vein, still with bearable pain in a scale of 4/10, complaints of slight itchiness in the upper extremities, V/S as follows: BP=100/70, T=37.2, PR=77, RR=20. DAY 3 August 7, 2012 (Post operative) 8:00 am Awake, coherent, sitting @ the edge of the bed, without IVF, pain noted @ surgical incision with pain scale of 4/10, complaints of itchiness in the whole body, V/S as follows: T=36.9, BP = 110/80, PR= 86, RR=18 2:00 pm Awake, conversant, coherent and oriented to time place and person; has no mobility restrictions and ambulatory. still with pain @ the surgical incision with pain scale of 3/10, abdominal girth of 28 inches, no complaints of itchiness, T=36.2, BP=110/80, PR=70, RR=20.
NURSING HISTORY
A. CHIEF COMPLAINTS/ REASON FOR VISIT Patient came to the hospital due to vaginal bleeding, pale in appearance, increase abdominal girth.
Two years prior to admission, patient have onset of profuse vaginal bleeding during her menstrual period, heaviest in the 2nd and 3rd day consuming up to 4pads per day, lasting 7days/period.CBC done noted, with decrease HGB, UTZ done with result of uterine myoma. Consulted and advise for tahbso at PGH. Few months prior to admission, patient consulted the attending physician, scheduled for hysterectomy hence admitted.
C. HISTORY OF PAST ILLNESS Patient has no food allergies, no chronic illnesses of previous accident. Patient had mumps when she was still 8years old. She was hospitalized for three days at Cebu Doctors Hospital last 2006 due o delivery of her first baby girl via NSVD G1 T1 P1 A0 L1 M0. Patient is a fully immunized child. She also had her flu vaccine last 2011. She also had her eye examination last 2011 with a visual acuity of 20/20. She also had her papsmear last 2011.