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7/31/2019 Surgery Hypothetical Case
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This is a case of a 34 year old female, married, Filipino, Roman Catholic, born onAugust 7, 1977. Patient came in due to her scheduled cesarean section underDr. Pamittan.
Past medical history includes: Had previous hospital admissions due to
appendectomy (1998), and dehydration due to gastroenteritis for severaloccasions with latest admission last 2001.
Family history reveals:Mother side: (+) HPN, (+) DMFather side: (+) TB, (+) gastric cancer, grandmother
Patient had no hypogastric pain, no vaginal bleeding, no vomiting, BOW notruptured yet and 90% effaced when she arrived at the OR. This is her secondpregnancy with first pregnancy also under CS (2005) due to cephalicdisproportion. Patient had regular prenatal care and is being treated for
Gestational diabetes and had been taking insulin injections with titrated dose 2xa day from 4th month of pregnancy until present.
Pre-op assessments are all normal including HGT. The patient tolerated theepidural anesthesia and the procedure well last July 3, 2012. The patients chartindicates this final diagnosis: PUFT Cephalic in Labor with alive Baby Boy G2P2(2-0-0-2) ; GDM.
Post Cesarean Section Orders are as follows;A. Transfer to post partum ward when stable.B. Vital signs monitoring q4h x 24 hours, I and O.
C. Bed rest x 6-8 hours, then ambulate; keep patient flat on back x 8 hoursIncentive spirometer q1h while awake.D. Diet: NPO x 8h, then sips of water. Advance to clear liquids, then DAT once w/
flatus.E.IV Fluids: IV D5 LR or D5 NS at 125 cc/h. Foley to gravity;
discontinue after 12 hours. I and O catheterize prn.
F.Medications1. Cefazolin (Ancef) 500 mg IV q 8 hrs x 2 days.2. Nalbuphine (Nubain) 5 to 10 mg SC or IV q2-3h4. Hydroxyzine (Vistaril) 25-50 mg IM q3-4h prn nausea.
G.Labs: CBC in AM -done
Postoperative Management for Day 1 post-opA. Assess pain, lungs, cardiac status, fundal height, lochia, passing
Of flatus, bowel movement, distension, tenderness, bowelsounds, incision.
B. Discontinue IV when taking adequate PO fluids Change meds to
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PO once on DAT.C. Discontinue Foley, and I and O catheterize prn.D. Ambulate TID with assistance; incentive spirometer q1h while
awake
Six hours post-partum assessment reveals normal physical examination exceptfor the post-operative wound in the lower abdomen and light vaginal bleeding.Other assessment reveals the following:
Weight: 71 kgsHeight: 5 feet and 6 inchesBP: 130/90 mmHgPR: 87RR 19HGT: 146 mg/dlPost-op pain scale: In the last six hours, highest is 9, lowest is 6.
Current is 8.
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LABORATORY / DIAGNOSTICS
Procedure / Date Actual Findings Normal Findings
1. CBCHemoglobin
Hematocrit
WBCSegmentersLymphocytesEosinophilsStab CellsPlatelets
116
0.358.00.600.140.020.04320
120 140 g/dL
0.305 10
0.36 - 0.660.22 - 0.400.01 - 0.040.02 - 0.05
150 400x9/L
2. Urinalysis:Microscopic Exam
ColorTransparencypHSpecific gravityEpithelial cellsChemical Exam
AlbuminSugar
Yellow
Hazel6.0
1.010Moderate
NegativeNegative
7.35 7.451.010 1.025