Name: Mrs. Sandra Pt. Encounter Number:
Date: 05/22/2018 Age: 24 Sex:
SUBJECTIVE
CC:
“My wife just delivered a baby at home and she is bleeding too much. Please help!”
HPI:
Patient was brought to the ER with profus
...
Name: Mrs. Sandra Pt. Encounter Number:
Date: 05/22/2018 Age: 24 Sex:
SUBJECTIVE
CC:
“My wife just delivered a baby at home and she is bleeding too much. Please help!”
HPI:
Patient was brought to the ER with profuse bleeding and retained placenta. Pt. is in hypovolemic shock,
in and out of consciousness, sweaty, cool to the touch, and extremely pale. BP 90/65, very weak pulse,
rapid heart rate and labored breathing. Husband told us she just had another stillbirth and it was a high
risk pregnancy due to anemia and pregnancy-induced hypertension. GTPAL (2-0-2-2-0). Pt. had regular
antenatal check-ups at primary health center. Because of her high- risk status and her previous stillbirth
(26 weeks), the health officer was worried and advised pt. to go to a hospital to deliver the baby.
Unfortunately patient didn’t take the advice and had a local private doctor attended her delivery, which
was very painful and resulted in another stillbirth (this time 28 weeks). MD immediately administered
oxygen and blood transfusion (PRBCs), but it was too late. Pulse and blood pressure dropped rapidly
and patient died. Doctors and nurses worked very hard but could not save her life.
Medications: Methyldopa 125mg per day for pregnancy induced hypertension.
( Prenatal Iron supplement for anemia)
PMH
Allergies: NKA
Medication Intolerances: NONE
Chronic Illnesses/Major traumas - Stillbirth in 2017 (26 weeks fetus).
Hospitalizations/Surgeries - 2017 due to stillbirth.
Family History
Father has hypertension. Mother is in good health.
Social History
Pt. lived with her husband and in-laws in a remote village. Her husband was a day laborer and the
family’s sole wage-earner (low economic level). Family mentioned that patient did not think her husband
would pay for her to go to have a baby in the hospital. No history of smoking or drinking.
ROS
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