Medical Record, Research Paper Example

Reproductive History

The patient has been admitted for abnormal uterine bleeding. She has been having this problem for a month and only became severe in the last few days. It is a new problem with no prior history of similar episodes. The abnormality of the bleeding is high magnitude of bleeding and the frequency has increases in the last few days. Abnormal pains and high blood pressure has accompanied the bleeding. The patient has had three children and none in the last five years.

Management

I performed surgery on the patient on the uterine wall to control the bleeding. The laboratory results indicated blood pressure of 120/80, pulse of 60 and temperature of 99F. There were low levels of cholesterol, at 75.0. The laboratory results indicate the patient had anemia. The patient had lost a lot of blood. Diagnosis was dysfunctional uterine bleeding.

Conclusion

The surgery was successful however the patient will need monitoring for the next four years. I have prescribed to her antibiotics and ion which should be taken for a week. Bed rest is recommended. Any other prescription relevant to her can be administered during her checkups. Closing monitoring of her blood pressure is required.