CASE: Placenta Previa

Date: March 03, 2021

PATIENT’S FIRST NAME: LAST NAME:

Ma. Cristina Crissandra Llarena

CIVIL STATUS: Divorced GENDER: Female

OCCUPATION: Nurse BIRTHDATE:11/09/1989

VITALS: AGE: 39 year old

BP = 90/60 mmhg  T =
36.0 C    P = 116 BPM     
R = 24 CPM

CHIEF COMPLAINT: HEIGHT:     156cm                                              WEIGHT:     80

Vaginal Bleeding kgs

HISTORY OF PRESENT ILLNESS PHYSICAL EXAM

 1 hour PTA patient
experienced bright red Neurovascular 
vaginal bleeding.  Patient was noted conscious and
 OB History (G4 T2 P0 A1 L2) coherent, GCS of 15/15 (E4, V5, M6),
 36 weeks AOG Normal Reflexes were noted.
 LMP 06-01-2020
 EDC 03-08-2021 Cardiovascular 
 Patient was noted with weak and thready
pulses upon palpation, Capillary Refill
Test = > 3 seconds.Approximate Blood
loss of 700ml. 

Respiratory
 Normal breathing was noted, clear breath
sounds were noted  on all lung fields
were noted upon auscultation.

GIT/GUT 
 Bright Red Vaginal Bleeding, Soft and
Non-Tender Abdomen, Cervix was open
at 3cm upon internal examination. 
  FHT of 165 BPM was noted thru the fetal
monitor.

Integumentary/Musculoskeletal
 Muscle strength of 5/5 all extremities,
skin was cold and clammy, palor was
noted, mottling of the skin was also
noted.

PAST MEDICAL HISTORY INITIAL DIAGNOSIS

 Patient was known Diabetic
for 3 years with Metformin Low-lying Total Placenta Previa
500mg tab 2x a day. Non
known other comorbidities.
 Patient was admitted last
2016 because of Pregnancy
complicated by Placenta
previa.
 Previous surgery (Dilatation FINAL DIAGNOSIS
and Curretage) was last
2015 because of
Spontaneous Abortion. 

ALLERGIES
 No known Allergy to Food
and Drugs

FAMILY HISTORY
 Patient has family history
Diabetes

SOCIAL HISTORY
 Patient has history smoking
2 packs per day 
 PHYSICIAN’S ORDER SHEET

PATIENT’S NAME: ATTENDING HOSPITAL ROOM

Ma. Cristina Crissandra PHYSICIAN: NO. NO.
Llarena Dra. Carandang 0074124
234

DATE/TIME/ASSESSMENT ORDER

March 03, 2021  Please admit the patient to the Delivery

08:00am Room under the service of Dra Carandang.

 Monitor I and O every 2 hours.

 Secure consent for admission and

Management.

Diagnostic:

 CBC with platelet count

 Retrieve old Sonography Results.
 ABO Blood Typing 
 Na,K, BUN,Crea

Treatment:

 Patient for Emergency Cesarean Section.

 Secure consent for Procedure
 Please refer patient to Anesthesiologist on
Deck
 Hooked patient to Cardiac monitor during 
 Please prepare 3 units of packed RBC
properly typed and Crossmatch.
 Fast Drip Plain NSS 500ml then followed by
Venoclysis with D5LR 1 Liter to run for 8
hours.
 Hooked to oxygen at 2-3 LPM via Nasal
Cannula.
 AP informed of this admission
 AOD informed of this admission.
 Refer accordingly.

                                      Dr. Mendiola
                                      Lic No. 00021212
                                      Emergency Medicine

March 03, 2021 Anesth notes NOTES

09:30am  s/p emergency cesarean section with
hysterectomy.
Diagnosis: Placenta Accreta (Increta)  Give tramadol 50mg IV every 8 hours as
needed for pain.
Approximate Blood Loss : 1300 ml  Ketorolac 30mg IV every 6 hours RTC.
 Transfuse 2 units of PRBC properly typed
and crossmatched to run for 4 hours each
unit..
 Continue IVF with D5LR 1 Liter x 8 hours
 Refer for any signs of bleeding.
 Refer accordingly.
    
                            Dr. Mailom
                            Lic No. 00025414
                            Anesthesiologist

March 03, 2021  Transfer patient to ICU.

10:30am  Refer patient to Dr. Quibal (IM Service) for
co-management.
Assessment :   Refer accordingly.
BP = 80/50 mmhg
HR = 125 BPM                                       Dra Carandang
RR = 22 CPM                                       Lic No. 00025463
Temp = 36.6 C                                       OB-GYNE
O2Sat = 98%
 No signs and symptoms of
Bleeding noted
 Weak thready pulses.
 Hgb of 7.9 on CBC
 HCT of 70%

March 03, 2021  Thank you for this referral.

10:50am  Patient seen and examined.
 Please maintain IVF rate @ 125ml/hr with
Assessment: D5LR.
 Weak thready pulses  Start Dopamine Drip @3mcg/kg/hr titrate
 Blood loss of Approximately accordingly to maintain SBP of at least
2000ml 110mmg.
 s/p cesarean section with  Maintain o2 support at 2-3 LPM via Nasal
hysterectomy secondary to Cannula.
placenta accreta (Increata)  Continue transfusion of 2 units PRBC
 Patient conscious and coherent properly typed and crossmatched.
 Monitor Vitals signs q 30 minutes.
 I and O every hour
 Refer for any untoward signs and symptoms.
 Refer accordingly.

                                     Dr. Quibal
                                     Lic No. 00025416
                                     Internal Medicine
March 03, 2021  Patient seen and examined s/p 2 units
07:00pm PRBC.
 May titrate down Dopamine until
Assessment discontinued.
 BP of 110/70mmhg  May discontinue O2 support
 HR = 102 BPM  Repeat CBC with platelet 6 hours post BT.
 RR = 22 CPM  Continue monitoring.
 Temp = 36.6 C
 O2Sat = 100%                            Dr. Abril
 No signs and symptoms of                            Lic. No. 00058476
bleeding noted.                            General Practitioner
 Full pulses.

March 04, 2021  Patient seen and examined.

10:00am  Patient seen clinically stable
 May Transfer to Regular Room of Choice.
Assessment
 BP of 120/70mmhg                                    Dra Carandang
 HR = 85 BPM                                    Lic No. 00025463
 RR = 18 CPM                                    OB-GYNE
 Temp = 36.6 C
 O2Sat = 100%
 No signs and symptoms of
bleeding noted.
 Full pulses.
 Dopamine Drip discontinued
March 03,2021 @10:15pm