Notes

* Final Report *
admission notes
Physician Note

Patient: SHAMLEENA KUNHOTH KUNHOTH KANDY MRN: MBH-00208595 FIN: 015612763
Age: 29 years Sex: Female DOB: 11/6/1989
Associated Diagnoses: Premature rupture of membranes, unspecified as to length of time between rupture and onset of labor, unspecified weeks of gestation
Author: Dr Megha Mathur

MRP: DR REHANA

Basic Information
Admit information: EMERGENCY .
Source of history: Self.
Present at bedside: Family member.
Referral source: Self.
History limitation: None.

Chief Complaint
PRIMIGRAVIDA AT 36 +1 WEEKS WITH LEAKING PERVAGINUM

History of Present Illness
Gravida: 4 Term: Preterm: Abortion: 3 Live babies:
LMP:2/1/2018
EDD:9/10/2018
FINAL EDD:09/10/2018
Gestational Age:36 weeks 1 day
High risk factors:
GDM on diett
Current Pregnancy:
- not booked in PHC
- conceived spontaneously
-early scan not done
- anomaly scan done at 20+6 wks = dates and normal


Booking Investigations

HIV: negative VDRL: HBsAg: : negative
Hb: 12 gm/dl Platelet: 387x1000 Blood gp& Rh:AB+ive
Urine culture : No growth Rubella:Immune
GTTdone Fasting : 5.38 mmol/l 2hrs : 5.5 mmol/l


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

Health Status
Allergies:
Allergic Reactions (All)
No Known Allergies
Current medications.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

Physical Examination
Vital Signs
12/9/2018 13:31 AST
Temperature Oral
36.5 DegC

Peripheral Pulse Rate
106 bpm HI

Respiratory Rate
18 br/min

Systolic Blood Pressure AA
148 mmHg HI

Diastolic Blood Pressure AA
93 mmHg HI

General: Alert and oriented.
Neurologic: Alert, Oriented.
Cognition and Speech: Oriented.
Psychiatric: Cooperative.
PER ABDOMEN: SFH: 34 cm
cephalic
uterus relaxed
PER SPECULUM: Clear liliquor draining
p/v: not done
CTG: REASSURING

Review / Management
Results review:
No qualifying data available
.

Impression and Plan
plan:
watch for vitals and pain abdomen and signs of chorioamniotis
Wait for spontaneous labour pains
send investigations
CTG monitoring 6 hrly
check fior urine albumin
apply sterile pad
if contraction starts;patient for benzyl penicillin
Diagnosis
Amniotic fluid leaking (ICD10-CM O42.90, Discharge, Medical).
Orders
Orders
Laboratory:
HVS (Order): HVS, Routine collect, 12/9/2018 15:25 AST, Once, Stop date 12/9/2018 15:25 AST, Lab Collect, Amniotic fluid leaking, Print Label By Order Location
Type and Screen (Order)
ABO/Rh Type (Order): Blood, Collect Routine, 12/9/2018 15:25 AST, Amniotic fluid leaking, Print Label By Order Location
Antibody Screen Gel (Order): Blood, Collect Routine, 12/9/2018 15:25 AST, Amniotic fluid leaking, Print Label By Order Location
CBC w/ Auto Diff (Order): Blood, Routine collect, 12/9/2018 15:25 AST, Once, Stop date 12/9/2018 15:25 AST, Lab Collect, Amniotic fluid leaking, Print Label By Order Location
Patient Care:
Urine Dipstick POC (Order): 12/9/2018 15:25 AST, Once, Stop Date 12/9/2018 15:25 AST.
Education and Follow-up:
Counseled: Patient, Family.
Discharge Planning: Plan to discharge ( To home, In 3-4 days ).
Anticipated Discharge Date: Anticipated Discharge Date: 15/09/2018.

Result type: Admission Note-Physician
Result date: 12 September, 2018 15:17 AST
Result status: Auth (Verified)
Result title: admission notes
Performed by: Dr Megha Mathur on 12 September, 2018 15:32 AST
Verified by: Dr Megha Mathur on 12 September, 2018 15:32 AST
Encounter info: 015612763, MBH Al Baraha, Inpatient, 12/9/2018 - 18/9/2018