VIRTUAL HOSPITAL PRACTICE

CASE ANALYSIS-OB WARD

2ND SEM. SY: 2019-2020

Elleine Ruth C. Mendoza, RN

Professor

SITUATION:
A 32-year-old multigravida patient on her 30th week of pregnancy came into
the Emergency room department with chief complaints sudden epigastric pain
associated with nausea and dizziness that started 3 hours prior to consultation.
Initial vital signs were taken as follows: BP: 170/100, PR: 95, RR: 17, Temperature:
36.8 degrees Celsius, FHT: 156 bpm with active fetal movement. During the
physical examination, edema was also noted on lower extremities. Internal
examination was done with no noted cervical dilation nor vaginal bleeding. Hence
Admission.

I. DEMOGRAPHIC DATA
Patients Name: Maria Juan
Age: 36
Sex: Female
Birthdate: April 28, 1984
Religion: Catholic
Race: Filipino
Marital Status: Married
Occupation: Housewife
Admitting Diagnosis: Pre-eclampsia
II. CHIEF COMPLAINT
Hypertension, Epigastric pain, Nausea, Dizziness

III. PAST MEDICAL HISTORY

With history of pre-eclampsia with the previous pregnancy, no known
allergies, no noted other medical problems. No other surgical procedures.
Non-smoker and non- alcohol drinker nor drug abuse.

IV. OBSTETRICAL HISTORY

LMP: October 1, 2019 G2P1(1001) with 30 weeks AOG on the present
pregnancy with regular prenatal check-up, tetanus toxoid completed
Last Delivery was 2017 via Emergency LSCS secondary to
preeclampsia

V. FAMILY HISTORY OF ILLNESS

 With family history of hypertension and diabetes.

VI. PHYSICAL EXAMINATION

General appearance: Weak in appearance
HEENT: Normal head contour, no lesions observed, moist mucos membranes
Skin: Pale in appearance, with bilateral pedal edema
Chest: with normal rhythm, no murmur noted, no adventitious breath sounds
heard
Abdomen: Gravid abdomen, soft non tender no masses palpated, striae
gravidarum, and linea nigra present
Reproductive: No discoloration, swelling, redness of genitalia, no bleeding,
closed cervix
VII. Laboratory Results
CBC: Normal Blood Count
Urinalysis: Negative for Glucose, 3+ Proteinuria, Negative ketones
Lipid Profile: HDL: 58, Cholesterol: 170, Triglyceride: 450

VIII. MEDICATIONS
1. Dexamethasone 4mg IM x 6 doses
2. Magnesium Sulfate 4 grams + 100 cc NSS as side drip x 1 hour for 20 doses
3. Methyldopa 250 mg/ tablet 1 tablet q 8 hours
REQUIREMENT:

 From the above situation formulate the following requirements in the

area.
Generic requirements:
1. 1 NCP (either actual or potential)
2. 13 Areas of Assessment or Head to Toe Assessment
3. Drug Study
4. 1 FDAR charting

 Submission of Requirements and time frame

1. To submit not later than May 30, 2020 in any manner…
(Messenger, Email, face to face, etc...)
2. Requirements submitted hard copy must be hand written by
the students ( coupon bond, yellow or pad paper)
3. If unable to submit, an INC grade is to be given to student
and is given one semester to comply.