Melissa Franks Telehealth and iHuman
Melissa-Franks Telehealth and iHuman
Melissa Franks Telehealth iHuman
iHuman and Telehealth Melissa
... [Show More] Franks
Melissa Franks Telehealth and iHuman
Nursing Notes from telehealth
• Melissa Franks 26 years old; 34 weeks & 3 days pregnant
• No known allergies
• Called into telehealth because she fell at 12:15pm going up her stairs and fell onto her stomach
• She is experiencing vaginal bleeding
• Vaginal bleeding is enough to fill a pad and explained it as “both dark red and bright”
• She rates her abdominal pain as 7/10; feels like an aching/pressure pain
• She also believes she has had about 5-6 contractions in the last hour since she fell; she feels her baby move in current time
• She is also experiencing back pain
• We have advised the patient to call 911 to get an ambulance to take her to the hospital
• She refused an ambulance and she stated she cannot afford that due to the current COVID-19 situation. She also expressed her concern about going to the ER and getting exposed to COVID-19.
• We advised to call a family member and that she needs to go to the ER immediately because her and her baby’s life is at risk.
• She expressed she would find someone to take her to the hospital and hung up the phone abruptly
iHuman
• Patient record review
o Melissa Franks: 26 years old, 5’8”, 166 lbs.
o Patient arrives at the emergency room at 1615
o Walk in to the emergency department
o fell at home; 34 weeks; heavy vaginal bleeding
o previous surgical history of appendectomy
o G3P1, first pregnancy a spontaneous vaginal delivery with no complications
o taking prenatal vitamins one tablet by mouth once daily
o unemployed
o reports a 40 lb weight gain with this pregnancy
o vaginal bleeding with dark red colored discharge/blood and no clots
o denies rupture of membranes
o tenderness with palpation over the umbilicus area; abdomen is firm, board-like during contractions
o contractions occurring sporadically and irregular
o BP 110/60, pulse 122, resp 22, temp 99.0
o fetal heart rate 160, moderate variability, no accelerations or decelerations
o ECG shows moderate separation of placenta 20%
o fetal weight estimate 6lbs 1 oz; biophysical profile 8/10; cephalic posterior presentation
o urinalysis positive for cocaine
o Fluid bolus
o Abnormal coagulation studies
• History
o ate a sandwich before this happened and some ice tea
o A&Ox3, pain in stomach and lower back; pain is stomach feels sharp in the middle
o fell down after she was kicked in the stomach
o swelling in her ankles at end of day
o notice a great amount of weight gain in this pregnancy
o pain radiates to back, pain 6/10 stomach, back pain 5/10
o taking prenatal vitamins and sometimes takes tylenol for a headache
o denies using cocaine
o one daughter and a boyfriend who is the father of both children
o boyfriend has threatened to harm or kill her and has used physical violence
o boyfriend has not harmed or threatened to harm children
• Physical
o Abrasion and redness to abdomen
o Heavy dark red vaginal bleeding
o Bruises to left upper extremity in various stages [Show Less]