Professional Documents
Culture Documents
case study postpartum hemoorhage
case study postpartum hemoorhage
case study postpartum hemoorhage
1. Student profile
2. Introduction
3. History collection
4. Physical examination
5. Vital signs
6. Investigations
7. Other investigations
8. Medication
10. Prognosis
Clinical specialty I
⮚ IDENTIFICATION OF DATA: -
1. Name of the patient : Mrs. Nisha Sharma
2. Age : 33 years
3. Gender : female
4. Bed no. :3
5. Educational Status : post. graduate
6. Occupation : House wife
7. Nationality : Indian
8. Religion : Hindu
9. Address : Hussainganj ,Lucknow
10. Marital Status : Married
11. Family members :7
12. Addiction : no any drug addiction
13. Diagnosis : Post partum haemorrhage
14. Consultant doctor : Dr. Kumkum
15. Source of information : husband
16. Date of Admission : 20-03-2024
17. Time of admission : 10:30 am
18. Obstetrical score : G2P1L1A0S0
19. LMP :20/07/2022 EDD :27/02/2023
⮚ CHIEF COMPLAINTS:-
● My client Mrs. Nisha was admitted seva hospital , Lucknow on 20/02/23 at 10:30 am
● bleeding episodes
● Increased urination
⮚ PERSONAL HISTORY:-
Tobacco chewing, cigarette smoking, alcohol, cola, coffee, tea : Tea
Diet: Vegetarian / Non-Vegetarian: Vegetarian
Allergies to any food item : No
No of meals and snacks /day : 3times a day
Likes & dislikes of food : Likes: Salty and Spicy , Dislikes: Sweet
Nutritional assessment 24 hours recall & recommended diet plan (for mothers on
therapeutic diet)
⮚ MENSTRUAL HISTORY:-
Age of Menarche -13 year
Duration of menstrual cycle - 28 days
Duration of menstrual cycle in days - 5 days
Regularity - Regular
Amount of flow - Normal
CONTRACEPTIVE HISTORY-
⮚ MARITAL HISTORY:-
Age of marriage- 5 years
Type of marriage- arranged
Consanguineous marriage- no
Relationship with husband- satisfied
No. of children- 2
Any sexual disorder- no
⮚ OBSTETRICAL HISTORY: -
Postnatal condition – After the birth of baby patient condition was normal in the
puerperium period.
Family Tree-
KEY
Male
Female
Female patient
FAMILY COMPOSITION-
1 Mr. Ramesh Father –in-law 63 year Male Graduation Private job Healthy
2 Mrs. Geeta Mother -in - 59year Female 8th Housewife Healthy
law
3 Mr. Ankur Husband 36 year Male P.G. Private job Healthy
4 Mrs. Nisha Patient 34 year Patient 12th Housewife Unhealth
y
5 Master Ansh Son 3 year Male - - Healthy
PSYCHOSOCIAL HISTORY:-
House- own
ENVIRONMENTAL HISTORY:-
She having clean house ,no environmental hazards, hand pump water supply, adequate
sanitation, adequate drainage system, adequate disposal method, and using public transport
service.
VITAL SIGN-
● Temperaure-101 F
INVESTIGATION CHART
INVESTIGATION PATIENT VALUE NORMAL VALUE REMARK
Complete Blood Count
11.4gm/dl 12-16gm/dl Normal
Hemoglobin
10900cells/mm 4000-11000 cll/mm3 Normal
TLC
Differential % Leukocytes
70% 40-80 Increased
count 26% 20-40 Normal
03% 1-6 Normal
01% 00-02 Normal
Neutrophils 2.61Lac million 1.5-4.5 Normal
Lymphocyte cells/ul
7.4-10.4 Increased
Eosinophils 11.9fl
3.8-4.8 Normal
Monocyte 3.94million cells/ul
27-32 Normal
Basophils 29.1pg
36-46 Decrease
Platelet count 33.7% 2.4-5.4 Normal
4.1mg/dl 10-45 Normal
19.9mg/dl 0.5-1.5 Normal
0.71mg/dl 70-110mg/dl
MPV Hyperglycemia
120mg/dl 100-140mg/dl
148.5mg/dl Hyperglycemia
Total RBC
MCH
HCT(Hemocrit)
Serum Uric Acid
Serum Urea
Serum Creatinine
gm glucose)
MEDIACATION
DRUG DOSE ROUTE FREQUENCY ACTION
General examination:
● Activity- Dull
● Behavior- Depressed
● Attitude-Co-operative
ANTHROPOMETRIC MEASUREMENT-
● Height-150 cm
● Weight-67 kg
● Abdominal Girth- 90 cm
SKIN-
● Color -Fair
● Turgor -Normal
● Texture -Smooth
● Pigmentation -Present
● Temperature -Normal
● Sensitivity -Sensitive
● Lesion -Present
● Scar -Absent
HEAD-
● Shape -Normal
● Symmetry - Symmetrical
● Dandruff -Present
● Pediculi -Absent
● Lesions -Absent
● Hair -Present
● Color - Black
● Texture -Normal
FACE-
● Symmetry -Symmetrical
EYES-
● Conjunctiva -Pale
● Sclera -whitish
● Style -Absent
● Cornea Transparent
● Vision Normal
EARS-
● Position -Normal
● Symmetry -Symmetrical
● Pain -Absent
NOSE-
LIPS:
● Hydration -Dry
● Symmetry -Symmetrical
● Lesion -Present
● Color -Pale
● Hydration -Poor
TEETH:
● No. of Teeth - 32
● Color -Yellowish
● Alignment -Normal
GUMS - Healthy
● Tongue - coated
● Color -Pink
● Hydration -dry
● Lesions -Absent
● Thickness -Normal
PALATE - Normal
NECK:
● Trachea -midline
● Lymph Node -Palpable
CHEST-
INSPECTION-
● Shape -Normal
● Movement -Symmetrical
● Retraction -Present
● Location of sternum-Midline
BREAST-
● Shape -Symmetrical
● Position -Normal
● Nipple -Cracked
PALPATION:
● Respiratory movement-Asymmetrical
● Fremitus -Normal
AUSCULATATION:
ABDOMEN-
INSPECTION:
● Shape -Rounded
● Skin -Normal
● Distension -Present
● Distended -Absent
● Umbilicus -Normal
PALPATION-
● Hepatomegaly -Absent
● Splenomegaly -Absent
● Tenderness -Present
● Mass -Absent
AUSCULTATION-
PERCUSSION-
● Ascites -Absent
BACK-
● Tenderness -Absent
● Mass -Absent
GENITALIA –
● External hemorrhoids-Absent
FEMALE
EXTRIMITIES-
● Position -Symmetrical
● Gait -Normal
● Congenital deformity-Absent
REFLEX-
OBSTETRICAL EXAMINATION
INSPECTION-
● Enlarged abdomen
PALAPTION-
● Abdominal Girth - 90 cm
AUSCULTATION-
OTHER INTERVENTIONS
Teach the patient regarding-
Breast Feeding-
Uterine changes-
● After pains or cramping are normal.This cramping means that the uterus is
contracting to return to its non-pregnant size. The uterus takes five to six weeks to
return to its non- pregnant size.
Vaginal Discharge-
● Usually lasts about ten days to four weeks. The color will change From bright red
to brownish to and will become less in amount and finally disappear .
● Menstruation period will resume in approximately six to eight weeks, unless
breastfeeding.
Care of Episiotomy-
● Sitzs bath-sitting in tub of warm water for 15 min , two to three minute times per
day will help relieve the discomfort.
● Stiches will dissolve in ne to three weeks.
Pain relief-
● Use a mild analgesic for breast engorgement , uterine cramps and episiotomy
discomfort.
● Continue taking prenatal iron and vitamin pills until postpartum visit.
● It is important to eat a well- balanced diet and drink plenty of fluids . drink two
quarts of fluid per day if on breast feeding
Emotional changes-
● You may feel let down ,anxious and cry easily.This is normal these feeling can
begin two to three days after delivery and usually disappear in about a week or
two.
Activity –
● It is advisable as soon as resume sexual intercourse ,Foam and condoms are safe
and east to use.
● Call obstetricians office two to three days after discharge to make an appointment
of six weeks.
Temperature- 100.2`F
Implementation-
2nd Day-
Patient complain- Patient condition is little bit better than the 1st day and her body
temperature is reduced.
Temp= 98`F
For improving the condition and maintaining the body temperature following implementation
is-
● Encouraged more Fluid intake
● Antipyretic medication.
3rd Day- After all these intervention patient body temperature is maintained . Now her
body temperature is normal.
Temperature- 98`F