8/18/2019 TempOb
1/1
DISCHARGE SUMMARY / HOSPITALABSTRACT
PATIENTNAME:
Enriquez, Rosselle Vergara SEX: F AGE: 20yo
A!MISSI"N#
$%$&!ATEA!MITTE!:
'()(20&*!I+ARGE!ATE:
'(&0(20&* R""M: $22-.
FINAL DIAGNOSIS: Gra/ia 2 Para 2 12002 Pregnan3y u4erine $% $(5
6ee7s, 3e89ali3, eli/ere s8on4aneously 4o a li/e 4er;a;y ;oy .<
2=7g AS ),= .S $)-'0 6ee7s, AGA
ADMITTING DIAGNOSIS: Gra/ia 2 Para 2 12002 Pregnan3y u4erine $%
$(5 6ee7s, 3e89ali3 in 8re4er la;or
CHIEF COMPLAINT: .looy s9o6
CLINICAL HISTORY :(First Trimester: Pa4ien4 9a usual signs an
sy84os o> 8regnan3y su39 as nausea an /oi4ingPregnan3y 4es4 6as
one an re/eale 8osi4i/e a>4er & on49 3essa4ion o>
ens4rua4ion PN+? 6ass4ar4e an s9e 6as gi/en 8rena4al ei3a4ions
Pa4ien4 enies 9is4ory o> a4ernal illness
Seco! Trimester: @ui37ening 6as >el4 on 49e %49 on49
o> 8regnan3y PN+? an in4a7e o> 8rena4al ei3a4ions 6ere
3on4inue
T"ir! Trimester: PN+? 6as 3on4inue Pa4ien4 6as a88aren4ly 6ell
un4il >e6 9ours 8rior, 8a4ien4 9a la;or 8ains Pa4ien4 49en
soug943onsul4 9en3e ai44e
LABORATORY FINDINGS:URINE STOOL BLOOD CHEMISTRY
#$RAYFINDINGS:ULTRASOUND RESULT:
OPERATIONPERFORMED:
Noral s8on4aneous eli/ery 6i49 eian e8isio4oy an re8air
HISTOPATHFINDINGS:
COURSE IN THE%ARD:
Pa4ien4 6as ai44e an 8u4 on NP" S9e 6as 9oo7e 4o IVF: !%R &
B ) ?4erine 3on4ra34ions 6ere
oni4ore 3losely S9e 9a s4a;le /i4al signs .aseline +TG 6as one
69i39 re/eale reassuringresul4 S9e 6as gi/en Nu;ain &a8 49ur
IV, oBy4o3in &0uni4s in3or8ora4e 4o IVF S9e e/en4uallyeli/ere
/ia noral s8on4aneous eli/ery 4o a li/e 4er ;a;y ;oy !ori3u &a8
an e49ergine&a8 /ia slo6 IV 8us9 S9e 6as 49en 4rans>erre 4o
re3o/ery roo 69ere /i4al signs 6ere oni4oreA>4er >e6 9ours,
s9e 6as sen4 ;a37 4o roo !ie4 6as 39ange 4o ie4 as 4olera4e T9e
>ollo6ingei3a4ions 6ere gi/en: AoBi3illin %00g(4a; $B a ay an
Me>enai3 A3i %00g(4a; e/ery*9ours
"n 49e 2n 9os8i4al ay, s9e 6as en3ourage ;reas4>eeing
eB3lusi/ely an early a;ula4ion S9e 6as a/ise 4o go 9oe an
9oeei3a4ions 6ere ins4ru34e
DISPOSITION: (ic&'!e "ome me!ictios) s*eci& istr'ctios)
! +o&&o, '*-En3ourage EB3lusi/e ;reas4>eeing an aily
8erenial 9ygiene TM: AoBi3illin %00g(4a; & 4a; $B a ay
>or 5ays, Me>enai3 a3i %00g(4a; & 4a; e/ery *9ours as
neee >or 8ainFollo6-u8 A8ril &), 20&*
PGI Gi R.o
NAME C SIGNAT?RENAME C SIGNAT?RE
RESI!ENT-IN-+ARGE
!r !el89ine +9ua
ATTEN!ING PDSI+IANLicese0
