Notes

* Final Report *

ADmission NOTES


Document Has Been Updated
admision
Physician Note

Patient: RASHA SAYED HOSNY RASHED MRN: MBH-00209512 FIN: 015647953
Age: 36 years Sex: Female DOB: 6/1/1982
Associated Diagnoses: Other specified postprocedural states
Author: Dr SAMREEN WASIF WASIF

Basic Information
Admit information: Admit with the complaint of lower abdominal pain .
Source of history: Self.
History limitation: None.
MRP:Dr wafaa

Chief Complaint
came with the complaint of lower abdominal pain

History of Present Illness
UN BOOKED PT (Booked in al qassmia hospital)
was admitted there on 14/9 signed LAMA on 16/918
G7 P3 L3 A3
LMP:31/12/2017
EDD:0710/2018 = Corresponding to scan done at 14 wks on 4/10/2018
37 wks
ADMITTED WITH CTG SHOWING 1/10 CONTRACIONS AND PATIENT C/O MILD PAIN
PATIENT finished DEXAMETHASONE
high risk:
previous 3 c section
premature ventricular contractions was on inderal stopped 2 months back

CURRENT PREGNANCY GA 37+1


*OBSTETRIC HISTORY G P +
prev 3 LSCS with Premature ventricular Contrac(on Indral for same), all cesaren on request

was seen by cardiology:
ECG SHOW 2/2018:
Normal sinus rhythm, bigeminy ---->monomorphic . controlled by small dose beta-blockers. indral 10mg bid,

ECG now 6/9/2018
normal sinus rhythm, no more premature beats.

normal echocardiography, with normal heart fuction.

since the patient had repeated C-section, patient is indicated for C-section for this delivery, as planned by her doctor, patient regarding cardiological point of veiw is stable, no more arrythmia nor symptoms, for time being, recommended to keep her K, and Mg, Hb level within normal before, during, and after delivery. choice of sedation during C-section according to anaethesia.




Review of Systems
Constitutional: Negative.
Respiratory: Negative.
Cardiovascular: Negative.
Gastrointestinal: Negative.

Health Status
Allergies:
Allergic Reactions (Selected)
No Known Allergies
Current medications: (Selected)
Inpatient Medications
Ordered
Ciprofloxacin Parenteral: 200 mg, IV, Once
Metoclopramide Parenteral: 10 mg, IV, Once
Paracetamol Parenteral: 1,000 mg, IV, Once
Ranitidine Parenteral: 50 mg, IV, Once
Prescriptions
Prescribed
Amoxicillin 500 mg/ Clavulanic Acid 125 mg Tablet: 1 tab(s), Oral, q8hr, 15 tab(s)
Calcium Carbonate 500mg Tablet: 1 tab(s), Oral, q24hr, 30 tab(s)
Folic Acid 1mg Tablet: 5 mg, Oral, q24hr
Multivitamin Tablet: 1 tab(s), Oral, q24hr, 30 tab(s)
Omeprazole 20mg Tablet: 1 tab(s), Oral, BID, 6 tab(s)
Potassium Chloride 600mg Tablet: 1 tab(s), Oral, q24hr, 5 tab(s)
Propranolol 10mg Tablet: 1 tab(s), Oral, BID, 180 tab(s)
Propranolol 10mg Tablet: 1 tab(s), Oral, BID, 28 tab(s)
Ranitidine 150mg Tablet: 1 tab(s), Oral, BID, 14 tab(s)
bisOPROLOL 2.5 mg oral tablet: 2.5 mg, Oral, q24hr
paracetamol 500mg Tablet: 2 tab(s), Oral, TID, 30 tab(s)
Problem list:
All Problems (Selected)
Ventricular bigeminy / SNOMED CT 19324019 / Confirmed
Persistent cough for 3 weeks or longer / SNOMED CT 423230012 / Confirmed
Pregnant / SNOMED CT 191073013 / Confirmed

Histories
Past Medical History.Family History:
Diabetes mellitus type II
Mother
Heart disease
Mother
Arthritis
Mother
Poor peripheral circulation
Mother
Weakness
Mother
Tingling
Mother
Back pain
Mother

Procedure history:
ceserian sections 3.
Social History

Social & Psychosocial Habits

Alcohol
11/12/2015 Risk Assessment: No Risk

Employment/School
09/05/2018 Status: Unemployed
Description: house waif
Highest education: Some college

Exercise
11/12/2015 Risk Assessment: Occasional exercise

09/05/2018 Duration (average number of minutes): 20
Times per week: 1-2 times/week
Self assessment: Good condition
Exercise type: Walking

Home/Environment
09/05/2018 Lives with: Children, Spouse
Home equipment: non
Alcohol abuse in household: No
Concerns about substance abuse in household: No
Smoker in household: No
Injuries/Abuse/Neglect in household: No
Feels unsafe at home: No
Safe place to go: Yes
Agency(s)/Others notified: No

Nutrition/Health
11/12/2015 Type of diet: Regular

09/05/2018 Diet description: non
Type of diet: Normal
Caffeine intake amount: yes
Diet restrictions: non
Vitamins/Supplements: iron and calciam
Wants to lose weight: No
Sleeping concerns: No
Feels highly stressed: No

Sexual
09/05/2018 Sexually active: No
First active at age: 24 Years
Uses condoms: No
History of sexual abuse: No

Social Situation (Marital Status)
09/05/2018 Marital Status Married
Number of Marriages: 1
Marriage Consanguinity: No
Number of Sons: 1
Number of Daughters: 2
Dependents: non
Living Arrangements: Apartment
Number of Bedrooms: 3
Pets: 0

Substance Abuse
11/12/2015 Risk Assessment: No Risk

09/05/2018 Type: non

Tobacco
11/12/2015 Risk Assessment: Medium Risk

09/05/2018 Use: Current every day smoker
Type: Pipe
Number of years: 15
Started at age: 18.0 Years
Previous treatment: None
Ready to change: No
Concerns about tobacco use in household: No

Psychosocial
03/19/2018 Domestic Concerns None
Emotional Support Available Yes
Financial Concerns Regarding Hospitalization/Discharge No
Coping Effective
Stressors Unknown cause
.

Physical Examination
Vital Signs
17/9/2018 22:49 AST
Temperature Oral
36.8 DegC

Peripheral Pulse Rate
78 bpm

Respiratory Rate
18 br/min

Systolic Blood Pressure AA
125 mmHg

Diastolic Blood Pressure AA
74 mmHg

Mean Arterial Pressure, Cuff AA
91 mmHg
17/9/2018 21:19 AST
Temperature Oral
37 DegC

Peripheral Pulse Rate
90 bpm

Respiratory Rate
18 br/min

Systolic Blood Pressure AA
117 mmHg

Diastolic Blood Pressure AA
63 mmHg

Pain assessment:
Self-reports pain
The location is: the pain is rated 4 /10 on the pain scale, abdomen.
Verbal descriptor scale rating of: mild pain.
The time pattern is: intermittent.
.
Psychiatric: Cooperative.
Obstetric Exam
Uterus: fundal height 35 cm.
Singleton/ Baby A fetal evaluation: fetal movement present, assessment of fetal heart tracing reassuring heart rate, fetal lie longitudinal, fetal presentation/ presenting part vertex.
Cervix: dilated not allowed properly, un co operative.

Review / Management
Laboratory Results
Last 5 Days Lab Results : PowerNote Discrete Results
14/9/2018 15:27 AST
ABO/Rh Interp
A POS
14/9/2018 15:23 AST
Sodium Lvl
133 mmol/L LOW

Potassium Lvl
4.2 mmol/L

Creatinine
42.10 umol/L LOW

Uric Acid
281 umol/L

Urea Lvl
1.50 mmol/L LOW
14/9/2018 15:17 AST
WBC
10.52 x10(3)/mcL

Hgb
13.10 gm/dL

Platelet
262.00 x10(3)/mcL
6/9/2018 10:30 AST
WBC
10.31 x10(3)/mcL

Hgb
12.80 gm/dL

Platelet
259.00 x10(3)/mcL

Sodium Lvl
136 mmol/L

Potassium Lvl
3.7 mmol/L

Creatinine
47.50 umol/L LOW

Uric Acid
291 umol/L

Urea Lvl
2.50 mmol/L




DIET PLAN: keep NPO
serology negative

Impression and Plan
Diagnosis
Orders
Diagnosis
Previous 3 cesarean section (ICD10-CM Z98.89, Admitting, Medical).
Orders
Orders
Nutrition & Dietetic Services:
NPO (Order): 17/9/2018 23:07 AST, Constant Indicator
Laboratory:
Red Blood Cell Order (Order): Blood, Routine collect, Collected, 17/9/2018 23:07 AST by Dr SAMREEN WASIF WASIF, Lab Collect, Previous 3 cesarean section, 2, 17/9/2018 23:07 AST, To Have Available
Type and Cross (Order)
ABO/Rh Type (Order): Blood, Collect Routine, 17/9/2018 23:07 AST, Previous 3 cesarean section, Print Label By Order Location
Antibody Screen Gel (Order): Blood, Collect Routine, 17/9/2018 23:07 AST, Previous 3 cesarean section, Print Label By Order Location
Crossmatch (Order): Blood, Collect Routine, 17/9/2018 23:07 AST, Previous 3 cesarean section, Print Label By Order Location
Pharmacy:
RINGER'S SOLUTION CONTINUOUS 500 mL (Order): 125 mL/hr, IV.
Education and Follow-up:
Counseled: Patient, Family.
Discharge Planning: Plan to discharge ( In 5 days ).
interdiscip[linary plan entered

patient and husband counselled about need of admission, if persistant pain for emergency cesarean section

Result type: Admission Note-Physician
Result date: 17 September, 2018 23:00 AST
Result status: Modified
Result title: admision
Performed by: Dr SAMREEN WASIF WASIF on 17 September, 2018 23:11 AST
Verified by: Dr SAMREEN WASIF WASIF on 17 September, 2018 23:11 AST
Encounter info: 015647953, MBH Al Baraha, Inpatient, 17/9/2018 -


Progress NOTEs


* Final Report *
Document Has Been Updated
post C- section follow up
Physician Note

Patient: RASHA SAYED HOSNY RASHED MRN: MBH-00209512 FIN: 015647953
Age: 36 years Sex: Female DOB: 6/1/1982
Associated Diagnoses: Encounter for cesarean delivery without indication
Author: Dr.Shivani Seth Vohra

seen with dr Rehana

Postoperative Information
post C-section day 2
Wound assessment:: The abdomen, No discharge, No drains.
Characteristics: Dry.
Incisional margin: Smooth.
Pain: mild.
Course: Improving.
Associated symptoms: Localized pain.
dressing done
stitch line healthy
passed stools
stool...not passed,
lochea :normal
Breast :soft, she started breast feeding

Review of Systems
Constitutional: Negative.
Gastrointestinal: Negative.
Genitourinary: Negative.
Psychiatric: Negative.

Health Status
Allergies:
Allergic Reactions (Selected)
No Known Allergies
Problem list.
Physical Examination
Vital Signs
19/9/2018 06:00 AST
Temperature Oral
36.7 DegC

Peripheral Pulse Rate
65 bpm

Respiratory Rate
18 br/min

Systolic Blood Pressure AA
111 mmHg

Diastolic Blood Pressure AA
76 mmHg

Mean Arterial Pressure, Cuff AA
88 mmHg

General: Alert and oriented.
per abdomin
soft,
pressure dressing removed

Review / Management
Results review:
Labs (Last four charted values)
WBC 10.74 (SEP 19)
Hgb L 11.60 (SEP 19)
Hct L 33.30 (SEP 19)
PT 11.00 (SEP 17)
INR 0.80 (SEP 17)
PTT 27.30 (SEP 17)
.
Laboratory Results

Impression and Plan
Diagnosis
Cesarean delivery delivered (ICD10-CM O82, Discharge, Medical).
Orders
PLAN
mobilzation
routine post operative care
councelled for excluisve breast feeding and mobilization
refer to arrythmia clinic in al qassimi after 6 weeks of delivery
-consult medical as she was on tab inderal ( stopped 2 months back)

Result type: Progress Note-Physician
Result date: 19 September, 2018 10:13 AST
Result status: Modified
Result title: post C- section follow up
Performed by: Dr.Shivani Seth Vohra on 19 September, 2018 10:17 AST
Verified by: Dr.Shivani Seth Vohra on 19 September, 2018 10:17 AST
Encounter info: 015647953, MBH Al Baraha, Inpatient, 17/9/2018 -



Discharge notes

* Final Report *



Admission Information
ADMITTED ON 14 -9-2018

SIGNED LAMA 16-9-2018

BOOKED PT
G7 P3 L3 A3
LMP:31/12/2017
EDD:0710/2018 = Corresponding to scan done at 14 wks on 4/10/2018
37 wks

ADMITTED WITH CTG SHOWING 1/10 CONTRACIONS AND PATIENT C/O MILD PAIN
PATIENT finished DEXAMETHASONE THIS MORNING
CROSS MATCH READY

ANC
prev 3 LSCS with Premature ventricular Contrac(on Indral for same)
PLANNED FOR LSCS AT 38 W
PAC DONE


Current Pregnancy:
Conception spontaneous
Non consanguineous marriage
Booked in PHC at 13 wks
Cardiac evaluation done in early pregnancy ,Echo normal ,on Indiral for PVCs
Booking BMI 25
Early scan at 14 wks in clinic corresponding with dates
Anomaly scan defaulted from 30/5/18 from AQWCH
GTT advised-defaulted
Serology Negative
Rubella advised



Physical Exam
Vitals & Measurements
T: 36.7 CELSIUS (Oral) RR: 18 BP: 114/72 SpO2: 100%




P/A
SOFT , NON TENDER
LAX UTERUS NO SCAR TENDERNESS

CTG NORMAL FETAL HEART TRACE NO CONTRACTION
COMPLAIN OF WATERY VAGINAL DISCHARGE ( AMNUSURE DONE NEGATIVE )


Discharge Plan
PATIENT WAS ADVISED TO STAY FOR OBSERVATION BUT SHE INSIST TO SIGN LAMA

PATIENT WAS COUNSELLED REGARDING RUPTURED OF MEMBRANE( INFECTION- GO WING IN TO LABOUR|)

PATIENT REFUSE TO STAY AND SIGNED LAMA PRO( MIS OHOOD ALNAEMI WAS CALLED )

PATIENT SIGNED LAMA





Encounter for supervision of high risk pregnancy in third trimester, antepartum


Ordered:


Discharge Patient



Pregnancy, supervision for, high-risk



Patient Discharge Condition
stable

Discharge Disposition
home


Operatb

* Final Report *
cesarean note
Physician Note

Patient: RASHA SAYED HOSNY RASHED MRN: MBH-00209512 FIN: 015647953
Age: 36 years Sex: Female DOB: 6/1/1982
Associated Diagnoses: Encounter for cesarean delivery without indication
Author: Dr SAMREEN WASIF WASIF

Procedure
Operative note- Caesarean Section

Date: 18/9/18 Time started: 01:33 Time finished: 02:07
Surgeon: dr wafaa Assistant: dr samreen type of anesthesia :GA on request
Anesthetist: dr amith Assistant nurse: sinimol Pediatrician:dr hiba
antibiotic timing : <60min category :2

Preoperative diagnosis:previous 3 in labour
Postoperative diagnosis:post cesarean section

Time out done
Findings:
1. Alive male baby, weight ( ) gm, APGAR 8 at 1 & 9at 5minutes.
2. Both ovaries & tubes normal;
3. Lower segment formed & intact
4. Others:bladder high up

Procedure:
Abdomen cleaned povidone-iodine or chlorhexidine & draped with sterile drape.
Incision: Abdomen opened through transverse supra-pubic incision by scalpel
Blunt dissection with the fingers of (subcutaneous tissue, fascia, rectus muscle and peritoneum)
Lower uterine segment identified, bladder peritoneum dissected and a lower segment uterine incision given
Alive Baby delivered at ( 01:35) handed to pediatrician, baby did not need resuscitation
Cord pH collected.
Placenta: Placenta & membranes delivered completely by Control cord traction..
Uterine closure: Both angles of uterine incision seen and taken separately under vision. Uterine cavity moped & closed in 2 layers, hemostasis achieved.
Abdominal closure: Abdominal cavity cleaned & inspected for any injury or bleeding (bladder base, muscle & peritoneum) and there is no active bleeding. Abdomen closed in layers (sheeth, corpus fascia, skin)
Skin closure: by sub-cuticular vicryl
Estimated blood loss:500ml
Count: correct
Urine: Clear urine draining ( 100) ml in the bag

complication :none
histopathology :not applicable
procedure tolerated well



Impression and Plan
Diagnosis
Orders
-Remove catheter after 8 hrs.
-Check power chart for post op medication.
- Start oral sips and soft diet after 8 hrs

Diagnosis
Cesarean delivery delivered (ICD10-CM O82, Discharge, Medical).
Orders
Orders
Pharmacy:
RINGER'S SOLUTION CONTINUOUS 500 mL (Discontinue): 125 mL/hr, IV.
Orders
Pharmacy:
enoxaparin (Order): 40 mg, Subcutaneous, Daily
Paracetamol Parenteral (Order): 1,000 mg, IV, q8hr, PRN: Pain / Fever
RINGER'S SOLUTION CONTINUOUS 1500 mL (Order): 125 mL/hr, IV
Promethazine Parenteral (Order): 25 mg, IM, q12hr, PRN: as needed for nausea/vomiting
Tramadol Parenteral (Order): 100 mg, IV, q12hr, PRN: Pain.

Result type: Operative Report
Result date: 18 September, 2018 02:17 AST
Result status: Auth (Verified)
Result title: cesarean note
Performed by: Dr SAMREEN WASIF WASIF on 18 September, 2018 02:21 AST
Verified by: Dr SAMREEN WASIF WASIF on 18 September, 2018 02:21 AST
Encounter info: 015647953, MBH Al Baraha, Inpatient, 17/9/2018 -