Past Medical/Surgical History: Mrs. Lucy Levi is a 32 year old female. Has been pregnant 4 times. . Question
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Past Medical/Surgical History: Mrs. Lucy Levi is a 32 year old female. Has been pregnant 4 times. Has 2 living children. Last pregnancy ended in miscarriage 2 years ago. Current pregnancy now 37 weeks. Has a history of, external hemorrhoids controlled with high fiber diet, exercise and topical Preparation H cream. Genital herpes last recorded outbreak was 6 months ago for which she was treated with Acyclovir. She has continued on a prescribed suppressive regimen of acyclovir since her 36th week of pregnancy as well. She does not smoke, or use alcohol or drugs. She does have a history of abusive spouse and has had several visits to her PCP for treatment of injuries sustained during violent episodes. She denies allergy to any drug or food.
Ms. Levi presented to the obstetrician’s office with complaints of regular contractions of the uterus, menstrual-like pressure above the pelvic bone, and lower backache. She reported that she has noticed an increased vaginal discharge that is streaked with blood. The client reports that the symptoms started 12 hours ago, after a violent altercation with her partner. She reports increased fetal movements. She denies rupture of membranes. She is anxious and concerned about the well-being of her baby since her last pregnancy ended in a miscarriage.
Dr. Kane examined Lucy, vital signs are within normal range, and fetal heart tones via doppler was 130 bpm. Uterine contractions are regular every 4 minutes and has caused changes to her cervix. Cervix is open, 10% effaced and long.
Ms. Levi states that she has been compliant with her suppressive regimen of acyclovir for genital herpes, and no lesions are noted currently.
She has bruises on her abdomen, thighs and upper arms. She told the doctor that she sustained the bruises when her spouse attacked her during a heated conversation earlier in the day.
Dr. Kane instructed the nurse to start an IV with 18 gauge catheter and 0.9 NS at 100 mL per hour. Insert 18-gauge indwelling catheter and transfer patient to the hospital for admission.
The doctor notified the authorities of the domestic abuse.
prepare an ISBAR for lucy levi
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Past Medical/Surgical History: Mrs. Lucy Levi is a 32 year old female. Has been pregnant 4 times.
