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    EMR Case Scenario

    Uploaded by

    Kristine Kim

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    © All Rights Reserved
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    EMR Case Scenario

    Uploaded by

    Kristine Kim
    39 views3 pages

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    39 views3 pages

    EMR Case Scenario

    Uploaded by

    Kristine Kim

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    You are on page 1of 3

    Angeles University Foundation

    College of Nursing

    NURSING INFOMATICS LABORATORY

    CASE SCENARIO FOR EMR ACTIVITY

    This is the case of a female patient, age 35, who was admitted to the hospital due acute vaginal
    bleeding. The patient claims to not have taken a pregnancy test yet and has an irregular menstrual
    cycle. Below is the patient's detailed course in the healthcare facility.

    Day 1 (June 1, 2020)

    Admission Notes:
    The patient was first seen at the ER, rushed into the facility by the husband, due to a an acute
    vaginal bleeding. After initial assessment and history taking, the following information were
    collected from the patient.
    Chief Complaint: Vaginal Bleeding Initial VS: (8 PM)
    Name: Dela Cruz, Kim Reyes Temp: 36.4 deg Celcius
    Age: 35 PR: 102
    Birthday: 12-May-85 RR: 24
    Nationality: Filipino BP: 105/65 mmHg
    Height: 5'5"
    Weight: 155 lbs.

    LMP: 20-Mar-20
    OB Hx: G1P1

    Physical assessment:
    Brief Hx: Patient reports of sudden vaginal bleeding 3 hrs prior to admission, bleeding
    was unprovoked and started while she was watching TV. She describes
    General: Consious and Coherent, guarding behavior over her abdominal region, (-) pain
    HEENT: PEERLA, anicteric sclera, pale palpebral conjuctiva, moist buccal mucosa
    Integ: CRT = 3seconds, pale nailbeds, good skin turgor, (-) lessions
    Cardio-respoiratory: (-) use of accessory breathing muscles, (-) murmur, adynamic precordium, PMI
    @ 5th ICS-MCL
    Genito-urinary: (-)dysuria, (+) vaginal bleeding - 3 fully soaked pads within the last 2 hours.
    Musculo-skeletal No weakness observed
    Allergies: Pollen

    ADMITTING DIAGNOSIS: ABNORMAL UTERINE BLEEDING, possible SPONTANEOUS


    ABORTION
    Admitting laboratory work-up
    Pregnancy test: (+) Urinalysis:
    CBC: Result Normal Color: Blood-tinged
    RBC 3.65 3.9-5.03 Specific Gravity: 1.01
    WBC 8520 3500-10500 pH: 7.01
    Hct 35.9 34.9-44.5 Protein: 1
    Hgb 110 120-155 RBC: 2
    Plt Ct 250,000 150,000-450,000 Bacteria: Absent
    Admitting Orders:
    * Admit patient to room of choice
    * Start IVF of D5LRs 1L x 100 cc/hr
    * Complete bed rest with no bathroom privileges
    * Place patient on DAT
    * For whole abdonimal ultrasound
    * VS q4, I & O q4, GCS q shift
    * Medications to be ordered after utz is completed
    * repeat CBC tomorrow morning
    * refer as needed

    Day 2 (June 2, 2020)

    Repeat CBC Result Normal


    RBC 3.9 3.9-5.03
    WBC 6590 3500-10500
    Hct 38 34.9-44.5
    Hgb 132 120-155
    Plt Ct 260,000 150,000-450,000
    * UTZ was completed at 8AM - revealed fetal part remnant
    * Patient was scheduled for D&C at 8 PM and was put on NPO starting 12 NN.
    * To start metronidazole, 500mg via IV infusion q8 ANST
    * Give paracetamol 500mg/tab PO and diphenhydramine 50mg/cap PO with sips of water 30 mins
    prior to transfer to OR
    * Secure consent for D&C

    VS 8:00 AM 12:00 PM 4:00 PM 8:00 PM


    T 36.5 36.4 36 36.1
    PR 108 102 98 105
    RR 18 21 19 20
    BP 110/60 110/70 105/65 110/60

    I&O
    6AM-6PM 6PM-6AM
    Intake: Output Intake: Output:
    IV: 1200 Oral 0 IV: 1200 Oral 0
    Oral 600 Urine 600 Oral 0 Urine 650
    Bleeding 120 Bleeding 50

    Nurse patient interaction


    * Nurse observed patient be nervous about upcoming D&C procedure. Patient was inquisitive about
    how the surgery would be done and what kind of post-operative scenarios she should expect. Other
    than this, the patiend does not verbalize any feelings of grief due to the loss of her baby. Patient was
    maintained on bed rest and the prescribed diet as ordered.

    * All meds were taken on time and as instructed


    Post-op Orders
    * WOF bleeding
    * Start mefenamic acid 500mg PO q6
    * Start ceftriaxone 750 mg IV q8 ANST
    * May resume DAT once fully awake
    * Nubain 5 mg SIVP q8-prn for severe pain
    * CBR s BP
    Day 3 (June 3, 2020)

    * Patient is now on her first post-operative day


    * Patien reports pain 7/10 over her abdominal area radiating down to her perineum. Patient
    describes pain as sharp and is provoked by movement. She is relieved by her pain medications that
    were started post operatively.
    * Patient is ubable to hold prolonged conversations due to pain.
    * Patient reports that post operative pain is relieved by nubain
    * Patient is still on CBR s BRP
    * Bleeding has become scanty
    * Patient has a folley catheter now after the surgery, draining amber colored urine
    VS 8:00 AM 12:00 PM 4:00 PM 8:00 PM
    T 36.8 36.5 36.9 36.4
    PR 90 95 85 80
    RR 18 22 24 20
    BP 120/80 120/70 110/60 110/60

    I&O
    6AM-6PM 6PM-6AM
    Intake: Output Intake: Output:
    IV: 1200 Oral 0 IV: 1200 Oral 0
    Oral 650 Urine 980 Oral 800 Urine 800
    Bleeding 30 Bleeding 10

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