Notes

Risk assessment and prophylaxis
Patient status (antenetal -)

Scoring VTE for the current status one risk factor.......
BMI > 30
Any contraindication for pharmacological thromboprophylaxsis yes




* Final Report *
post c section
Physician Note

Patient: SHAMLEENA KUNHOTH KUNHOTH KANDY MRN: MBH-00208595 FIN: 015612763
Age: 29 years Sex: Female DOB: 11/6/1989
Associated Diagnoses: Encounter for cesarean delivery without indication
Author: Dr SAMREEN WASIF WASIF

Postoperative Information
post C-section day: 3
INDICATION G4 P0A3 WITH 36 WEEKS + 3 DAYS GESTATION WITH PPROM 48 HOURS WITH FAILURE OF INDUCTION OF LABOUR
Urine: passing without complaint
Stool: passed
Lochia: normal
Breast: soft, breast feeding started
Baby in SCBU
tsh: 2.9

cracked nipple present, latching improved, seen by lactation
per abdomen-soft, non tender
no induartion or redness around wound


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

Health Status
Allergies:
Allergic Reactions (Selected)
No Known Allergies,
Allergies (1) Active Reaction
No Known Allergies None Documented

Current medications: (Selected)
Inpatient Medications
Ordered
Beta Sitosterol 0.25% 30GM Ointment: 1 app, TOP, q24hr
Bromhexine 4mg/5mL Syrup: 4 mg, 5 mL, Oral, q8hr
Paracetamol Oral: 1,000 mg, 2 tab(s), Oral, q6hr, PRN: Pain / Discomt
Thyroxine Oral: 75 mcg, Oral, q24hr
enoxaparin: 40 mg, 1 EA, Subcutaneous, q24hr
Problem list:
All Problems
Psoriasis / SNOMED CT 15886015 / Confirmed

Histories
Family History:
High blood pressure
Mother
Diabetes
Father

Procedure history:
No active procedure history items have been selected or recorded.
Social History

Social & Psychosocial Habits

Alcohol
09/13/2018 Risk Assessment: Denies Alcohol Use

Employment/School
09/02/2018 Status: Unemployed
Description: housewife
Activity level: Moderate physical work
Highest education: University degree(s)

Exercise
09/02/2018 Risk Assessment: Does not exercise

Home/Environment
09/02/2018 Lives with: Spouse
Living situation: Home/Independent
Home equipment: nil
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: Yes
Safe place to go: No
Agency(s)/Others notified: No
Family/Friends available to help: Yes
Concern for family members at home: No
Major illness in household: No
Financial concerns: No
Religious restrictions/concerns: nil

Nutrition/Health
09/02/2018 Diet description: regular diet
Type of diet: Normal
Caffeine intake amount: nil
Diet restrictions: nil
Wants to lose weight: No
Sleeping concerns: No
Feels highly stressed: No
Comment: low nutritional rislk - 09/02/2018 11:18 - Liba Anu K Mathew

Social Situation (Marital Status)
09/02/2018 Marital Status Married
Number of Marriages: 1
Living Arrangements: Apartment

Substance Abuse
09/02/2018 Risk Assessment: Denies Substance Abuse

Tobacco
09/02/2018 Risk Assessment: Denies Tobacco Use

Psychosocial
09/02/2018 Domestic Concerns None
Emotional Support Available Yes
Financial Concerns Regarding Hospitalization/Discharge No
Coping Effective
Stressors Condition
.

Physical Examination
VS/Measurements
PER ABDOMEN UTERUS WELL CONTRACTED DRESSING IS DRY AND CLEAN
PER VAGINA LOCHIA IS HEALTHY
General: Alert and oriented.
Neurologic: Alert, Oriented.
Psychiatric: Cooperative.

Review / Management
Results review:
Labs (Last four charted values)
WBC 9.96 (SEP 15) H 14.91 (SEP 12)
Hgb L 11.20 (SEP 15) 13.20 (SEP 12)
Hct L 33.30 (SEP 15) 39.50 (SEP 12)
Glucose Fasting 4.7 (SEP 16)
.

Impression and Plan
Diagnosis
Delivered by cesarean section (ICD10-CM O82, Post-Op Diagnosis, Medical).

plan-
mobilization
watch vitals
inform if any concern

Result type: Progress Note-Physician
Result date: 17 September, 2018 13:54 AST
Result status: Auth (Verified)
Result title: post c section
Performed by: Dr SAMREEN WASIF WASIF on 17 September, 2018 13:56 AST
Verified by: Dr SAMREEN WASIF WASIF on 17 September, 2018 13:56 AST
Encounter info: 015612763, MBH Al Baraha, Inpatient, 12/9/2018 - 18/9/2018