History
Vitals
Labs
Orders
Notes
G2P2, vaginal delivery 3 days ago, uncomplicated pregnancy, no chronic conditions.G2P2,3天前陰道分娩,懷孕過程無併發症,無慢性病史。
BP 150/98 mmHg at discharge, HR 88, RR 16, T 98.6°F.出院時血壓150/98 mmHg,心率88,呼吸16,體溫98.6°F。
Hgb 11.2 g/dL, Hct 34%, platelets 210,000/µL.血紅素11.2 g/dL,血比容34%,血小板210,000/µL。
Discharge instructions: monitor for warning signs, follow-up in 2 weeks.出院衛教:監測警訊,2週後回診。
Client reports severe headache and blurred vision since last night. Denies chest pain or heavy bleeding.產婦主訴昨晚開始嚴重頭痛及視力模糊。否認胸痛或大量出血。