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FORM NO.

IIFb-26
Republic of the Philippines
Department of Health
JOSE R. REYES MEMORIAL MEDICAL CENTER
Department of Obstetrics and Gynecology

RESIDENTS 24-HOUR OB-GYNE HISTORY


DATE: December 6, 2016 SEXUAL HISTORY:
HOSPITAL NO.: 622080 First Sexual Contact: 17
ATTENDING PHYSICIAN: Dr. Cuenca/ Alava/ Number of Sexual Partners: 1
Morante/Naguit/ Beron/ Donato/ Rodriquez Contraceptive: Oral contraceptive none
-------------------------------------------------------------------------------
----- OBSTETRIC HISTORY:
GENERAL DATA: LMP: March 5, 2016
Name: Dela Cruz, Rema Jallane Age: 19 y/o AOG: 38 weeks 6/7 days
Civil Status: Single Birthday: 05/12/1997 EDC: December 10, 2016
Religion: Roman Catholic
Address: Tondo Manila G1P0
Gravida Outcom Route Place BW Complicati
CHIEF COMPLAINT: Labor pain Year e of ons
Birth
HISTORY OF PRESENT ILLNESS: G1 Present
2016 Pregnan
1st trimester: cy
The patient noted cessation of menstruation.
Pregnancy test was done at home and it tested positive. PHYSICAL EXAMINATION:
Patient started prenatal check-up and was given General Survey: Patient is conscious, coherent, and not
Multivitamins. Ultrasound was done. Negative for any in cardiorespiratory distress, with the following vital
maternal illness. signs:
BP: 120/90mmhg CR: 88 RR: 20 T: 36.5oC
2nd Trimester: HEENT: Anicteric sclera, pink palpebral conjunctiva, no
Patient continued her prenatal check-up and nasal and aural discharge, no tonsillopharyngeal
continued above medications. Ultrasound was done. No congestion, no cervical lymphadenopathy, no neck vein
vomiting, nausea and vaginal bleeding. Noted good fetal engorgement
movement. Chest and Lungs: Symmetrical chest expansion, no
retractions, with clear breath sound, no crackles or
3rd Trimester: wheezes
Patient continued her prenatal check-up and Heart: Adynamic precordium, normal rate, regular
continued above medications. nausea and vaginal rhythm, no heaves, lifts, thrills, or presence of murmur,
bleeding. Negative for any maternal illness. apex beat located at 5th intercostal space midclavicular
line
Few hours prior to admission, the patient noted Breast: Symmetrical contour, no dimpling, no palpable
vaginal bleeding accompanied by hypogastric pain. mass, no tenderness, no abnormal nipple discharge
Hence sought consult in our institution. Abdomen: Globular, soft, no tenderness noted upon
palpation, normoactive bowel sounds
PAST MEDICAL HISTORY: FH: 34
(-) HPN (-) Heart Disease (-) Previous surgery FHT: 157
(-) DM (-) PTB (-) Thyroid disease
(-) Asthma (-) Liver Disease (-) Kidney LM1: Breech LM3: cephalic
Disease LM2: Fetal back maternal right LM4: not engaged

FAMILY HISTORY: Extremities: grossly normal extremities, no


(-) HPN (-) Thyroid disease (-) PTB deformities, no cyanosis, no edema
(-) DM (-) Heart Disease (-) Asthma Skin: brown, warm to touch, moist, with good skin
(-) Liver Disease (-) Kidney Disease turgor, capillary refill <2 sec
(-) Malignancy SPECULUM EXAM: Cervix smooth, violaceous
INTERNAL EXAMINATION: Cervix 3 cm dilated,
PERSONAL AND SOCIAL HISTORY: Beginning Effecement, Ruptured Bag of Water, Cephalic,
(-) Smoking Station -3
(-)Alcoholic beverage drinker
(-) Illicit Drug Use ASSESSMENT: Gravida 1 Para 0 Pregnancy Uterine 39
(-) Allergy to food and drugs weeks 3/7 days Age of Gestation by Last Menstrual
Period, Cephalic in Beginning Labor.
Educational Attainment: College graduate
Employment: unemployed PLAN: for Normal Spontaneous Delivery

MENSTRUAL HISTORY:
Menarche: 11 years old
Interval: 28-30 days
Duration: 4-5 days
Amount: 3 pads per day, moderately soaked
Symptoms: (-) Dysmenorrhea

GYNECOLOGIC HISTORY:
(-) Dyspareunia (-) Post Coital Bleeding
(-) Chronic Pelvic Pain (-) Foul-smelling discharge
(-) Postcoital bleeding

JRRMMC-F-OBG-IIF-20 February 20, 2016 Revision No.: 0 Page 1 of 1


FORM NO. IIFb-26
Republic of the Philippines
Department of Health
JOSE R. REYES MEMORIAL MEDICAL CENTER
Department of Obstetrics and Gynecology

Menarche: 16 years old


Interval: 28-30 days
Duration: 3-4 days
Amount: 2 pads per day, fully soaked
Symptoms: (-) Dysmenorrhea
RESIDENTS 24-HOUR OB-GYNE HISTORY
DATE: December 6, 2016
HOSPITAL NO.: 2016097669 GYNECOLOGIC HISTORY:
ATTENDING PHYSICIAN: Dr. Cuenca/ Alava/ (-) Dyspareunia (-) Post Coital Bleeding
Morante/Naguit/ Beron/ Donato/ Rodriquez (-) Chronic Pelvic Pain (-) Foul-smelling discharge
------------------------------------------------------------------------------- (-) Postcoital bleeding
-----
GENERAL DATA:
Name: Lumandas, Yau-Mae Age: 19 y/o
Civil Status: Married Birthday: 02/16/1997 SEXUAL HISTORY:
Religion: Roman Catholic First Sexual Contact: 17
Address: Number of Sexual Partners: 1
Contraceptive: None
CHIEF COMPLAINT: Labor Pains
OBSTETRIC HISTORY:
HISTORY OF PRESENT ILLNESS: LMP: April 2, 2016
PMP: March 2016
1st trimester: AOG: 35 weeks 3/7 days
The patient noted cessation of menstruation. EDC: January 1, 2017
Pregnancy test was done at home and it tested positive.
Patient started prenatal check-up at Sampaloc lying-in G2P1 (1001)
and was given Multivitamins, ferrous sulfate and calcium Gravida Outcom Route Place of BW Complic
+ vitamin D3. Ultrasound was not done. No nausea, Year e Birth ations
vomiting and vaginal spotting. Negative for any maternal G1(201 Live Normal Valenzuel 2.3 None
illness. 6) term spontaneo a Health kilogr
us delivery ams
center
2nd Trimester: G2(201 Present pregnancy
Patient continued her prenatal check-up and 6)
continued above medications. Ultrasound was done with
unremarkable results No vomiting, nausea and vaginal PHYSICAL EXAMINATION:
bleeding. Noted good fetal movement. General Survey: Patient is conscious, coherent, and not
in cardiorespiratory distress, with the following vital
3rd Trimester: signs:
Patient continued her prenatal check-up and BP: 90/60mmhg CR: 86 RR: 16 T: 36.5 oC
continued above medications. Ultrasound was done. No HEENT: Anicteric sclera, pink palpebral conjunctiva, no
nausea, vomiting and vaginal spotting. Negative for any nasal and aural discharge, no tonsillopharyngeal
maternal illness. congestion, no cervical lymphadenopathy, no neck vein
engorgement
One day prior to admission, the patient Chest and Lungs: Symmetrical chest expansion, no
experience hypogastric pain and lumbosacral pain. No retractions, with clear breath sound, no crackles or
vaginal bleeding, discharge, dysuria, diarrhea and fever. wheezes
Few hours prior to admission, hypogastric pain Heart: Adynamic precordium, normal rate, regular
persisted, No vaginal bleeding and discharge. rhythm, no heaves, lifts, thrills, or presence of murmur,
Few minutes prior to admission, hypogastric apex beat located at 5th intercostal space midclavicular
pain persisted associated with watery vaginal discharge. line
Hence sought consult in our institution. Breast: Symmetrical contour, no dimpling, no palpable
mass, no tenderness, no abnormal nipple discharge
PAST MEDICAL HISTORY: Abdomen: Globular, soft, no tenderness noted upon
(-) HPN (-) Heart Disease (-) Previous surgery palpation, normoactive bowel sounds
(-) DM (-) PTB (-) Thyroid disease
(-) Asthma (-) Liver Disease (-) Kidney FH: 34
Disease FHT: 157

FAMILY HISTORY: LM1: Breech LM3: cephalic


(-) HPN (-) Thyroid disease (-) PTB LM2: Fetal back maternal right LM4: engaged
(-) DM (-) Heart Disease (-) Asthma
(-) Liver Disease (-) Kidney Disease Extremities: grossly normal extremities, no
(-) Malignancy deformities, no cyanosis, no edema
Skin: brown, warm to touch, moist, with good skin
PERSONAL AND SOCIAL HISTORY: turgor, capillary refill <2 sec
(-) Smoking SPECULUM EXAM: Cervix smooth, violaceous, with
(-)Alcoholic beverage drinker minimal bleeding
(-) Illicit Drug Use INTERNAL EXAMINATION: Cervix soft 9cm dilated,
(-) Allergy to food and drugs 90% effaced, intact bag of water, cephalic, station -2

Educational Attainment: Highschool graduate ASSESSMENT: Gravida 2 Para 1 (1001) Pregnancy


Employment: unemployed Uterine 35 3/7 weeks Age of Gestation by Last Menstrual
Period, Cephalic in Preterm Labor
MENSTRUAL HISTORY:

JRRMMC-F-OBG-IIF-20 February 20, 2016 Revision No.: 0 Page 1 of 1


FORM NO. IIFb-26
Republic of the Philippines
Department of Health
JOSE R. REYES MEMORIAL MEDICAL CENTER
Department of Obstetrics and Gynecology

PLAN: Awaits delivery Educational Attainment: College graduate


Employment: unemployed

MENSTRUAL HISTORY:
Menarche: 12 years old
Interval: 28-30 days
Duration: 5 days
Amount: 4 pads per day, moderately soaked
Symptoms: (+) Dysmenorrhea

RESIDENTS 24-HOUR OB-GYNE HISTORY GYNECOLOGIC HISTORY:


DATE: December 6, 2016 (-) Dyspareunia (-) Post Coital Bleeding
HOSPITAL NO.: 2016097771 (-) Chronic Pelvic Pain (-) Foul-smelling discharge
ATTENDING PHYSICIAN: Dr. Cuenca/ Alava/ (-) Postcoital bleeding
Morante/Naguit/ Beron/ Donato/ Rodriquez
------------------------------------------------------------------------------- SEXUAL HISTORY:
----- First Sexual Contact: 31 years old
GENERAL DATA: Number of Sexual Partners: 1
Name: DeJonggoy, Vicky C. Age: 39 years old Contraceptive: Oral contraceptive none
Civil Status: Single Birthday: 05/21/1977
Religion: Roman Catholic OBSTETRIC HISTORY:
Address: Masambong, Quezon City LMP: February 24, 2016
AOG: 40 6/7 weeks by LMP
CHIEF COMPLAINT: Labor pains AOG: 38 4/7 weeks by 2nd trimester ultrasound
EDC: November 30, 2016
HISTORY OF PRESENT ILLNESS:
G3P2 (2002)
1st trimester: Gravida Outcom Route Place BW Complicati
The patient noted cessation of menstruation. Year e of ons
Pregnancy test was done at home and it tested positive. Birth
Patient started prenatal check-up at Masambong Quezon G1- Female, NSD Lying AGA No
City Health Center where she was given ferrous sulfate 2009 alive In complicati
and calcium + vitamin D3. Negative for any maternal term Quez on
illness. on
City
2nd Trimester: G2 Female, NSD Home AGA No
Patient continued her prenatal check-up and -2011 alive deliv compliatio
continued above medications. Ultrasound was done. No term ery n
vomiting, nausea and vaginal bleeding. Noted good fetal G3 - Present
movement. 2016 Pregnan
cy
3rd Trimester:
Patient continued her prenatal check-up and PHYSICAL EXAMINATION:
continued above medications. Ultrasound was requested General Survey: Patient is conscious, coherent, and not
which revealed breech presentation. At 7 th month of in cardiorespiratory distress, with the following vital
pregnancy, usual blood pressure was 130-140/ 80- 100. signs:
Methyldopa 250mg/tab was prescribed, non-compliant to BP: 180/130mmhg CR: 114 RR: 20 T: 36.9oC
medication. No noted nausea and vaginal bleeding. HEENT: Anicteric sclera, pink palpebral conjunctiva, no
Negative for any maternal illness. nasal and aural discharge, no tonsillopharyngeal
congestion, no cervical lymphadenopathy, no neck vein
Few hours prior to admission, the patient noted engorgement
vaginal bleeding accompanied by hypogastric pain. Chest and Lungs: Symmetrical chest expansion, no
Hence sought consult in our institution. retractions, with clear breath sound, no crackles or
wheezes
PAST MEDICAL HISTORY: Heart: Adynamic precordium, normal rate, regular
(+) HPN: Methyldopa 250mg/cap TID (-) Heart rhythm, no heaves, lifts, thrills, or presence of murmur,
Disease apex beat located at 5th intercostal space midclavicular
(-) Previous surgery (-) DM (-) PTB line
(-) Thyroid disease (-) Asthma (-) Breast: Symmetrical contour, no dimpling, no palpable
Liver Disease mass, no tenderness, no abnormal nipple discharge
(-) Kidney Disease Abdomen: Globular, soft, no tenderness noted upon
palpation, normoactive bowel sounds
FAMILY HISTORY: FH: 32cm
(-) HPN (-) Thyroid disease (-) PTB FHT: 150s
(-) DM (-) Heart Disease (-) Asthma
(-) Liver Disease (-) Kidney Disease (-) LM1: Breech LM3: cephalic
Malignancy LM2: Fetal back maternal left LM4: not engaged

PERSONAL AND SOCIAL HISTORY: Extremities: grossly normal extremities, no


(-) Smoking deformities, no cyanosis, no edema
(-)Alcoholic beverage drinker Skin: brown, warm to touch, moist, with good skin
(-) Illicit Drug Use turgor, capillary refill <2 sec
(-) Allergy to food and drugs
Speculum exam: Cervix smooth, violaceous

JRRMMC-F-OBG-IIF-20 February 20, 2016 Revision No.: 0 Page 1 of 1


FORM NO. IIFb-26
Republic of the Philippines
Department of Health
JOSE R. REYES MEMORIAL MEDICAL CENTER
Department of Obstetrics and Gynecology

(-) Dyspareunia (-) Post Coital Bleeding


Internal examination: Cervix 2 cm dilated, 50% (-) Chronic Pelvic Pain (-) Foul-smelling discharge
effaced, intact bag of water, cephalic, Station -3 (-) Postcoital bleeding

ASSESSMENT: Gravida 3 Para 2 Pregnancy Uterine 40 SEXUAL HISTORY:


6/7 weeks Age of Gestation by Last Menstrual Period; First Sexual Contact: 15 year old
Preeclempsia, Severe Number of Sexual Partners: 1
Contraceptive: Oral contraceptive none
PLAN: for Augmentation, Assisted Vaginal Delivery
OBSTETRIC HISTORY:
LMP: February 12, 2016
PMP: November 2015
Menoupause: N/A

RESIDENTS 24-HOUR OB-GYNE HISTORY


DATE: December 6, 2016 G8P8 (8008)
HOSPITAL NO.: Gravida Outcom Route Place BW Complicati
ATTENDING PHYSICIAN: Dr. Cuenca/ Alava/ Year e of ons
Morante/Naguit/ Beron/ Donato/ Rodriquez Birth
------------------------------------------------------------------------------- G1 - Male, AGA Tondo AGA None
----- 1988 Term Genera Complicati
GENERAL DATA: alive l on
Name: Adeva, Maria Luz Age: 50 years old Hospit
Civil Status: Single Birthday: February 6, a
1966 G2 Female, AGA Home AGA None
Religion: Roman Catholic 1989 Term deliver Complicati
Address: Manila alive y on
G3 Female, AGA Home AGA None
CHIEF COMPLAINT: Difficulty of Breathing 1990 Term deliver Complicati
alive y on
HISTORY OF PRESENT ILLNESS: G4 Female, AGA Tondo AGA None
1991 Term Genera Complicati
Patient is a known case of cervical cancer stage alive l on
IIIB last January 2016. Hospit
Few hours prior to consult, the patient al
G5 Male AGA Tondo AGA None
experienced difficulty of breathing associated with
1992 Term Genera
hypogastric pain. Due to persistence of symptoms,
alive l
patient was brought to our institution.
Hospit
al
PAST MEDICAL HISTORY:
G6 - Male AGA Tondo AGA None
(-) HPN (-) Heart Disease (-) Previous surgery
1999 Term Genera
(-) DM (-) PTB (-) Thyroid disease
alive l
(-) Asthma (-) Liver Disease (-) Kidney
Hospit
Disease
al
G7- Female AGA Tondo AGA None
FAMILY HISTORY: 2000 Term Genera
(-) HPN (-) Thyroid disease (-) PTB alive l
(-) DM (-) Heart Disease (-) Asthma Hospit
(-) Liver Disease (-) Kidney Disease al
(-) Malignancy G8 - Female AGA Lying AGA None
2006 Term In
PERSONAL AND SOCIAL HISTORY: alive Malabo
(-) Smoking n
(-)Alcoholic beverage drinker
(-) Illicit Drug Use PHYSICAL EXAMINATION:
(-) Allergy to food and drugs General Survey: Patient is conscious, coherent, and not
in cardiorespiratory distress, with the following vital
Educational Attainment: High school graduate signs:
Employment: unemployed BP: 90/70mmhg CR: 105 RR: 24 T: 36.5oC
HEENT: Anicteric sclera, pink palpebral conjunctiva, no
MENSTRUAL HISTORY: nasal and aural discharge, no tonsillopharyngeal
Menarche: 12 years old congestion, no cervical lymphadenopathy, no neck vein
Interval: 30 days engorgement
Duration: 3 days Chest and Lungs: Symmetrical chest expansion, no
Amount: 3 pads per day, moderately soaked retractions, with clear breath sound, no crackles or
Symptoms: (+) Dysmenorrhea wheezes
Heart: Adynamic precordium, normal rate, regular
GYNECOLOGIC HISTORY: rhythm, no heaves, lifts, thrills, or presence of murmur,

JRRMMC-F-OBG-IIF-20 February 20, 2016 Revision No.: 0 Page 1 of 1


FORM NO. IIFb-26
Republic of the Philippines
Department of Health
JOSE R. REYES MEMORIAL MEDICAL CENTER
Department of Obstetrics and Gynecology

apex beat located at 5th intercostal space midclavicular PAST MEDICAL HISTORY:
line (-) HPN (-) Heart Disease (-) Previous surgery
Breast: Symmetrical contour, no dimpling, no palpable (-) DM (-) PTB (-) Thyroid disease
mass, no tenderness, no abnormal nipple discharge (-) Asthma (-) Liver Disease (-) Kidney
Abdomen: Globular, soft, no tenderness noted upon Disease
palpation, normoactive bowel sounds
FAMILY HISTORY:
Extremities: grossly normal extremities, no (-) HPN (-) Thyroid disease (-) PTB
deformities, no cyanosis, no edema (-) DM (-) Heart Disease (-) Asthma
Skin: brown, warm to touch, moist, with good skin (-) Liver Disease (-) Kidney Disease
turgor, capillary refill <2 sec (-) Malignancy

Speculum exam: cervix is closed with minimal bleeding PERSONAL AND SOCIAL HISTORY:
(-) Smoking
Internal examination: (-)Alcoholic beverage drinker
(-) Illicit Drug Use
ASSESSMENT: Squamous Cell Carcinoma, Stage IIIB (-) Allergy to food and drugs

PLAN: For Medical Management Educational Attainment: Highschool graduate


Employment: unemployed

MENSTRUAL HISTORY:
Menarche: 13 years old
Interval: Irregular
Duration: 3-4 days
Amount: 3 pads per day, moderately soaked
Symptoms: (-) Dysmenorrhea

GYNECOLOGIC HISTORY:
(-) Dyspareunia (-) Post Coital Bleeding
(-) Chronic Pelvic Pain (-) Foul-smelling discharge
(-) Postcoital bleeding

RESIDENTS 24-HOUR OB-GYNE HISTORY


DATE: December 6, 2016 SEXUAL HISTORY:
HOSPITAL NO.: 759154 First Sexual Contact: 16
ATTENDING PHYSICIAN: Dr. Cuenca/ Alava/ Number of Sexual Partners: 2
Morante/Naguit/ Beron/ Donato/ Rodriquez Contraceptive: Oral contraceptive none
-------------------------------------------------------------------------------
----- OBSTETRIC HISTORY:
GENERAL DATA: LMP: February 27, 2016
Name: Dela Cruz, Uldarica Age: 37 y/o PMP: January 2016
Civil Status: Married Birthday: 01/19/1979 AOG: 40 weeks by LMP
Religion: Baptist EDC: December 3, 2016
Address: Tondo Manila
G6P3 (3023)
CHIEF COMPLAINT: Labor pain Gravida Outcom Route Place BW Complicati
Year e of ons
HISTORY OF PRESENT ILLNESS: Birth
G1 Female, NSD Fabell AGA none
1st trimester: 1996 Term a
The patient noted cessation of menstruation. alive
Pregnancy test was done at home and it tested positive. G2 Male NSD Fabell AGA none
Patient started prenatal check-up and was given Ferrous 1999 Term a
sulfate and caclcium+D3. Ultrasound was done. alive
Negative for any maternal illness. G3 Male NSD Fabell AGA none
2003 Term a
2nd Trimester: alive
Patient continued her prenatal check-up and G4 Abortion Abortion
continued above medications. Ultrasound was done. No 2008
G5 Abortion Abortion
vomiting, nausea and vaginal bleeding. Noted good fetal
2009
movement.
G6 Present
2016 Pregnan
3rd Trimester:
cy
Patient continued her prenatal check-up and
continued above medications. nausea and vaginal
PHYSICAL EXAMINATION:
bleeding. Negative for any maternal illness.
General Survey: Patient is conscious, coherent, and not
in cardiorespiratory distress, with the following vital
Few hours prior to admission, the patient noted
signs:
vaginal bleeding accompanied by hypogastric pain.
BP: 130/90mmhg CR: 81 RR: 20 T: 36.8oC
Hence sought consult in our institution.
HEENT: Anicteric sclera, pink palpebral conjunctiva, no
nasal and aural discharge, no tonsillopharyngeal

JRRMMC-F-OBG-IIF-20 February 20, 2016 Revision No.: 0 Page 1 of 1


FORM NO. IIFb-26
Republic of the Philippines
Department of Health
JOSE R. REYES MEMORIAL MEDICAL CENTER
Department of Obstetrics and Gynecology

congestion, no cervical lymphadenopathy, no neck vein (-) DM (-) Heart Disease (-) Asthma
engorgement (-) Liver Disease (-) Kidney Disease
Chest and Lungs: Symmetrical chest expansion, no (-) Malignancy
retractions, with clear breath sound, no crackles or
wheezes PERSONAL AND SOCIAL HISTORY:
Heart: Adynamic precordium, normal rate, regular (-) Smoking
rhythm, no heaves, lifts, thrills, or presence of murmur, (-)Alcoholic beverage drinker
apex beat located at 5th intercostal space midclavicular (-) Illicit Drug Use
line (-) Allergy to food and drugs
Breast: Symmetrical contour, no dimpling, no palpable
mass, no tenderness, no abnormal nipple discharge Educational Attainment: High school graduate
Abdomen: Globular, soft, no tenderness noted upon Employment: unemployed
palpation, normoactive bowel sounds
FH: 30 MENSTRUAL HISTORY:
FHT: 140s Menarche: 12 years old
Interval: 30 days
LM1: Breech LM3: cephalic Duration: 3 days
LM2: Fetal back maternal right LM4: engaged Amount: 3 pads per day, moderately soaked
Symptoms: (+) Dysmenorrhea
Extremities: grossly normal extremities, no
deformities, no cyanosis, no edema GYNECOLOGIC HISTORY:
Skin: brown, warm to touch, moist, with good skin (-) Dyspareunia (-) Post Coital Bleeding
turgor, capillary refill <2 sec (-) Chronic Pelvic Pain (-) Foul-smelling discharge
SPECULUM EXAM: Cervix smooth, violaceous (-) Postcoital bleeding
INTERNAL EXAMINATION: Cervix 7 cm dilated, 80%
Effacement, Ruptured Bag of Water, Cephalic, Station -2 SEXUAL HISTORY:
ASSESSMENT: Gravida 6 Para 3 Pregnancy Uterine 40 First Sexual Contact: 15 year old
weeks Age of Gestation by Last Menstrual Period, Number of Sexual Partners: 1
Currently in Labor. Contraceptive: Oral contraceptive none

PLAN: for Normal Spontaneous Delivery OBSTETRIC HISTORY:


LMP: February 12, 2016
PMP: November 2015
Menoupause: N/A

G8P8 (8008)
Gravida Outcom Route Place BW Complicati
Year e of ons
Birth
G1 - Male, NSD Tond AGA None
1988 Term o Complicati
RESIDENTS 24-HOUR OB-GYNE HISTORY alive Gene on
DATE: December 6, 2016 ral
HOSPITAL NO.: 2016014902 Hospi
ATTENDING PHYSICIAN: Dr. ta
Bagadiong/Brazal/Soriano/Barcial/ Villanueva G2 Female, NSD Home AGA None
------------------------------------------------------------------------------- 1989 Term deliv Complicati
----- alive ery on
GENERAL DATA: G3 Female, NSD Home AGA None
Name: Adeva, Maria Luz Age: 50 year old 1990 Term deliv Complicati
Civil Status: Single Birthday: February 6, alive ery on
1966 G4 Female, NSD Tond AGA None
Religion: Roman Catholic 1991 Term o Complicati
Address: Manila alive Gene on
ral
CHIEF COMPLAINT: Difficulty of Breathing Hospi
tal
G5 Male NSD Tond AGA None
HISTORY OF PRESENT ILLNESS:
1992 Term o
alive Gene
Patient is a known case of cervical cancer stage
ral
IIIB last January 2016.
Hospi
Few hours prior to consult, the patient
tal
experienced difficulty of breathing associated with
G6 - Male NSD Tond AGA None
hypogastric pain. Due to persistence of symptoms,
1999 Term o
patient was brought to our institution.
alive Gene
ral
PAST MEDICAL HISTORY:
Hospi
(-) HPN (-) Heart Disease (-) Previous surgery
tal
(-) DM (-) PTB (-) Thyroid disease G7- Female NSD Tond AGA None
(-) Asthma (-) Liver Disease (-) Kidney 2000 Term o
Disease alive Gene
ral
FAMILY HISTORY: Hospi
(-) HPN (-) Thyroid disease (-) PTB tal

JRRMMC-F-OBG-IIF-20 February 20, 2016 Revision No.: 0 Page 1 of 1


FORM NO. IIFb-26
Republic of the Philippines
Department of Health
JOSE R. REYES MEMORIAL MEDICAL CENTER
Department of Obstetrics and Gynecology

G8 - Female NSD Lying AGA None stage IV.


2006 Term In Few hours prior to consult, the patient
alive Mala experienced vaginal pain associated with hypogastric
bon pain. Due to persistence of symptoms, patient was
brought to our institution.
PHYSICAL EXAMINATION:
General Survey: Patient is conscious, coherent, and not PAST MEDICAL HISTORY:
in cardiorespiratory distress, with the following vital (-) HPN (-) Heart Disease (-) Previous surgery
signs: (-) DM (-) PTB (-) Thyroid disease
BP: 90/70mmhg CR: 105 RR: 24 T: 36.5oC (-) Asthma (-) Liver Disease (-) Kidney
HEENT: Anicteric sclera, pink palpebral conjunctiva, no Disease
nasal and aural discharge, no tonsillopharyngeal
congestion, no cervical lymphadenopathy, no neck vein FAMILY HISTORY:
engorgement (-) HPN (-) Thyroid disease (-) PTB
Chest and Lungs: Symmetrical chest expansion, no (-) DM (-) Heart Disease (-) Asthma
retractions, with clear breath sound, no crackles or (-) Liver Disease (-) Kidney Disease
wheezes (-) Malignancy
Heart: Adynamic precordium, normal rate, regular
rhythm, no heaves, lifts, thrills, or presence of murmur, PERSONAL AND SOCIAL HISTORY:
apex beat located at 5th intercostal space midclavicular (-) Smoking
line (-)Alcoholic beverage drinker
Breast: Symmetrical contour, no dimpling, no palpable (-) Illicit Drug Use
mass, no tenderness, no abnormal nipple discharge (-) Allergy to food and drugs
Abdomen: Globular, soft, no tenderness noted upon
palpation, normoactive bowel sounds Educational Attainment: High school graduate
Employment: unemployed
Extremities: grossly normal extremities, no
deformities, no cyanosis, no edema MENSTRUAL HISTORY:
Skin: brown, warm to touch, moist, with good skin Menarche: 16 years old
turgor, capillary refill <2 sec Interval: 38-32 days
Duration: 3-5 days
Speculum exam: cervix is closed with minimal bleeding Amount: 3 pads per day, moderately soaked
Symptoms: (+) Dysmenorrhea
Internal examination:
GYNECOLOGIC HISTORY:
ASSESSMENT: G8P8 Squamous Cell Carcinoma, Stage (-) Dyspareunia (-) Post Coital Bleeding
IIIB (-) Chronic Pelvic Pain (-) Foul-smelling discharge
(-) Postcoital bleeding
PLAN: For Medical Management; anemia and electrolyte
correction SEXUAL HISTORY:
First Sexual Contact: 19 year old
Number of Sexual Partners: 1
Contraceptive: Oral contraceptive none

OBSTETRIC HISTORY:
LMP: June, 2016
PMP: May 2016
Menoupause: N/A

RESIDENTS 24-HOUR OB-GYNE HISTORY


DATE: December 6, 2016
HOSPITAL NO.: 639920 G4P4 (4004)
ATTENDING PHYSICIAN: Dr. Carino/Perez/Joves Gravida Outcom Route Place BW Complicati
------------------------------------------------------------------------------- Year e of ons
----- Birth
GENERAL DATA: G1 - Female, NSD QCGH AGA None
Name: Millet, Emmaliza Age: 48 year old 1992 Term
Civil Status: Widowed Birthday: May 7, alive
1968 G2 Male, NSD QCGH AGA None
Religion: Roman Catholic 1993 Term
Address: Meycauayan Bulacan alive
G3 Male, QCGH Home AGA None
1995 Term deliv
CHIEF COMPLAINT: Vaginal pain
alive ery
HISTORY OF PRESENT ILLNESS:

Patient is a known case of pelvic organ prolapse

JRRMMC-F-OBG-IIF-20 February 20, 2016 Revision No.: 0 Page 1 of 1


FORM NO. IIFb-26
Republic of the Philippines
Department of Health
JOSE R. REYES MEMORIAL MEDICAL CENTER
Department of Obstetrics and Gynecology

G4 Male, QCGH Tond AGA None -------------------------------------------------------------------------------


1996 Term o -----
alive Gene GENERAL DATA:
ral Name: Millet, Emmaliza Age: 48 year old
Hospi Civil Status: Widowed Birthday: May 7,
tal 1968
Religion: Roman Catholic
PHYSICAL EXAMINATION: Address: Meycauayan Bulacan
General Survey: Patient is conscious, coherent, and not
in cardiorespiratory distress, with the following vital CHIEF COMPLAINT: vaginal pain
signs:
BP: 120/80mmhg CR: 82 RR: 19 T: 36.2oC HISTORY OF PRESENT ILLNESS:
HEENT: Anicteric sclera, pink palpebral conjunctiva, no
nasal and aural discharge, no tonsillopharyngeal Patient is a known case of pelvic organ prolapse
congestion, no cervical lymphadenopathy, no neck vein stage IV.
engorgement Few hours prior to consult, the patient
Chest and Lungs: Symmetrical chest expansion, no experienced vaginal pain due to the protusion of the
retractions, with clear breath sound, no crackles or tissue at the front wall of the vagina, associated with
wheezes vaginal bleeding (spotting) , dysuria and constipation.
Heart: Adynamic precordium, normal rate, regular Due to persistence of symptoms, patient sought consult
rhythm, no heaves, lifts, thrills, or presence of murmur, in Gyne-Onco opd , was admiited and was advised to do
apex beat located at 5th intercostal space midclavicular suegery.
line
Breast: Symmetrical contour, no dimpling, no palpable PAST MEDICAL HISTORY:
mass, no tenderness, no abnormal nipple discharge (-) HPN (-) Heart Disease (-) Previous surgery
Abdomen: Globular, soft, no tenderness noted upon (-) DM (-) PTB (-) Thyroid disease
palpation, normoactive bowel sounds (-) Asthma (-) Liver Disease (-) Kidney
Disease
Extremities: grossly normal extremities, no
deformities, no cyanosis, no edema FAMILY HISTORY:
Skin: brown, warm to touch, moist, with good skin (-) HPN (-) Thyroid disease (-) PTB
turgor, capillary refill <2 sec (-) DM (-) Heart Disease (-) Asthma
(-) Liver Disease (-) Kidney Disease
Speculum exam: cervix is closed with minimal bleeding (-) Malignancy

Internal examination: PERSONAL AND SOCIAL HISTORY:


(-) Smoking
ASSESSMENT: Pelvic Organ Prolapse stage IV (-)Alcoholic beverage drinker
(-) Illicit Drug Use
PLAN: For Medical Management (-) Allergy to food and drugs

Educational Attainment: High school graduate


Employment: unemployed

MENSTRUAL HISTORY:
Menarche: 16 years old
Interval: 38-32 days
Duration: 3-5 days
Amount: 3 pads per day, moderately soaked
Symptoms: (+) Dysmenorrhea

GYNECOLOGIC HISTORY:
(-) Dyspareunia (-) Post Coital Bleeding
(-) Chronic Pelvic Pain (-) Foul-smelling discharge
(-) Postcoital bleeding

SEXUAL HISTORY:
First Sexual Contact: 19 year old
Number of Sexual Partners: 1
Contraceptive: Oral contraceptive none

OBSTETRIC HISTORY:
LMP: June, 2016
PMP: May 2016
Menoupause: N/A

RESIDENTS 24-HOUR OB-GYNE HISTORY


DATE: December 6, 2016
HOSPITAL NO.: 639920
ATTENDING PHYSICIAN: Dr.
Carino/Perez/Joves/Morante/ Naguit/ Beron,
Donato/ Rodriguez

JRRMMC-F-OBG-IIF-20 February 20, 2016 Revision No.: 0 Page 1 of 1


FORM NO. IIFb-26
Republic of the Philippines
Department of Health
JOSE R. REYES MEMORIAL MEDICAL CENTER
Department of Obstetrics and Gynecology

G4P4 (4004)
Gravida Outcom Route Place BW Complicati
Year e of ons
Birth RESIDENTS 24-HOUR OB-GYNE HISTORY
G1 - Female, NSD QCGH AGA None DATE: December 6, 2016
1992 Term HOSPITAL NO.: 622080
alive ATTENDING PHYSICIAN: Dr. Cuenca/ Alava/
G2 Male, NSD QCGH AGA None Morante/ Naguit/ Beron, Donato/ Rodriguez
1993 Term -------------------------------------------------------------------------------
alive -----
G3 Male, QCGH Home AGA None GENERAL DATA:
1995 Term deliv Name: Dela Cruz, Rema Jallane Age: 19 y/o
alive ery Civil Status: Single Birthday: 05/12/1997
G4 Male, QCGH Tond AGA None Religion: Roman Catholic
1996 Term o
alive
Address: Tondo Manila
Gene
ral CHIEF COMPLAINT: Labor pain
Hospi
tal HISTORY OF PRESENT ILLNESS:
PHYSICAL EXAMINATION: 1st trimester:
General Survey: Patient is conscious, coherent, and not The patient noted cessation of menstruation.
in cardiorespiratory distress, with the following vital Pregnancy test was done at home and it tested positive.
signs: Patient started prenatal check-up and was given
BP: 120/80mmhg CR: 82 RR: 19 T: 36.2oC Multivitamins. Ultrasound was done. Negative for any
HEENT: Anicteric sclera, pink palpebral conjunctiva, no maternal illness.
nasal and aural discharge, no tonsillopharyngeal
congestion, no cervical lymphadenopathy, no neck vein 2nd Trimester:
engorgement Patient continued her prenatal check-up and
Chest and Lungs: Symmetrical chest expansion, no continued above medications. Ultrasound was done. No
retractions, with clear breath sound, no crackles or vomiting, nausea and vaginal bleeding. Noted good fetal
wheezes movement.
Heart: Adynamic precordium, normal rate, regular
rhythm, no heaves, lifts, thrills, or presence of murmur, 3rd Trimester:
apex beat located at 5th intercostal space midclavicular Patient continued her prenatal check-up and
line continued above medications. nausea and vaginal
Breast: Symmetrical contour, no dimpling, no palpable bleeding. Negative for any maternal illness.
mass, no tenderness, no abnormal nipple discharge
Abdomen: Globular, soft, no tenderness noted upon Few hours prior to admission, the patient noted
palpation, normoactive bowel sounds vaginal bleeding accompanied by hypogastric pain.
Hence sought consult in our institution.
Extremities: grossly normal extremities, no
deformities, no cyanosis, no edema PAST MEDICAL HISTORY:
Skin: brown, warm to touch, moist, with good skin (-) HPN (-) Heart Disease (-) Previous surgery
turgor, capillary refill <2 sec (-) DM (-) PTB (-) Thyroid disease
(-) Asthma (-) Liver Disease (-) Kidney
Speculum exam: not done Disease
Internal examination: not done FAMILY HISTORY:
(-) HPN (-) Thyroid disease (-) PTB
ASSESSMENT:Gravida 4 Para 4 (4004) Pelvic Organ (-) DM (-) Heart Disease (-) Asthma
Prolapse stage IV (-) Liver Disease (-) Kidney Disease
(-) Malignancy
PLAN: For Vaginal Hysterectomy, Kelly plication, Anterior
Posterior repair PERSONAL AND SOCIAL HISTORY:
(-) Smoking
(-)Alcoholic beverage drinker
(-) Illicit Drug Use
(-) Allergy to food and drugs

Educational Attainment: College graduate


Employment: unemployed

MENSTRUAL HISTORY:
Menarche: 11 years old
Interval: 28-30 days
Duration: 4-5 days
Amount: 3 pads per day, moderately soaked
Symptoms: (-) Dysmenorrhea

GYNECOLOGIC HISTORY:
(-) Dyspareunia (-) Post Coital Bleeding
(-) Chronic Pelvic Pain (-) Foul-smelling discharge

JRRMMC-F-OBG-IIF-20 February 20, 2016 Revision No.: 0 Page 1 of 1


FORM NO. IIFb-26
Republic of the Philippines
Department of Health
JOSE R. REYES MEMORIAL MEDICAL CENTER
Department of Obstetrics and Gynecology

(-) Postcoital bleeding

SEXUAL HISTORY:
First Sexual Contact: 17
Number of Sexual Partners: 1
Contraceptive: Oral contraceptive none

OBSTETRIC HISTORY: RESIDENTS 24-HOUR OB-GYNE HISTORY


LMP: March 5, 2016 DATE: December 6, 2016
AOG: 38 weeks 6/7 days HOSPITAL NO.: 2016032743
EDC: December 10, 2016 ATTENDING PHYSICIAN: Dr.
Bagadiong/Brazal/Soriano/Barcial/ Villanueva
G1P0 -------------------------------------------------------------------------------
Gravida Outcom Route Place BW Complicati -----
Year e of ons GENERAL DATA:
Birth Name: Pagallaman, Dolores Panganiban Age: 37
G1 Present years old
2016 Pregnan Civil Status: Widowed Birthday:
cy May 26, 1976
Religion: Roman Catholic
PHYSICAL EXAMINATION: Address: Malabon City
General Survey: Patient is conscious, coherent, and not
in cardiorespiratory distress, with the following vital CHIEF COMPLAINT: Difficulty of breathing
signs:
BP: 120/90mmhg CR: 88 RR: 20 T: 36.5oC HISTORY OF PRESENT ILLNESS:
HEENT: Anicteric sclera, pink palpebral conjunctiva, no
nasal and aural discharge, no tonsillopharyngeal Patient is a known case of squamous cell
congestion, no cervical lymphadenopathy, no neck vein carcinoma, cervix stage III B (August, 2016) undergone 4
engorgement cycles chemotherapy and 30 days of radiation therapy.
Chest and Lungs: Symmetrical chest expansion, no Few days prior to admission, patient experience
retractions, with clear breath sound, no crackles or difficulty of breathing associated with abdominal
wheezes enlargement. Due to persistence of symptoms, patient
Heart: Adynamic precordium, normal rate, regular was brought to our institution.
rhythm, no heaves, lifts, thrills, or presence of murmur,
apex beat located at 5th intercostal space midclavicular PAST MEDICAL HISTORY:
line (-) HPN (-) Heart Disease (+)Previous surgery:
Breast: Symmetrical contour, no dimpling, no palpable CS(2005)
mass, no tenderness, no abnormal nipple discharge (-) DM (-) PTB (-) Thyroid disease
Abdomen: Globular, soft, no tenderness noted upon (-) Asthma (-) Liver Disease (-) Kidney
palpation, normoactive bowel sounds Disease
FH: 34
FHT: 157 FAMILY HISTORY:
(-) HPN (-) Thyroid disease (-) PTB
LM1: Breech LM3: cephalic (-) DM (-) Heart Disease (-) Asthma
LM2: Fetal back maternal right LM4: not engaged (-) Liver Disease (-) Kidney Disease
(-) Malignancy
Extremities: grossly normal extremities, no
deformities, no cyanosis, no edema PERSONAL AND SOCIAL HISTORY:
Skin: brown, warm to touch, moist, with good skin (-) Smoking
turgor, capillary refill <2 sec (-)Alcoholic beverage drinker
SPECULUM EXAM: Cervix smooth, violaceous (-) Illicit Drug Use
INTERNAL EXAMINATION: Cervix 3 cm dilated, (-) Allergy to food and drugs
Beginning Effecement, Ruptured Bag of Water, Cephalic,
Station -3 Educational Attainment: High school graduate
ASSESSMENT: Gravida 1 Para 0 Pregnancy Uterine 39 Employment: unemployed
weeks 3/7 days Age of Gestation by Last Menstrual
Period, Cephalic in Beginning Labor. MENSTRUAL HISTORY:
Menarche: 14 years old
PLAN: for Normal Spontaneous Delivery Interval: 28 days
Duration: 3 days
Amount: 3 pads per day, moderately soaked
Symptoms: (+) Dysmenorrhea

GYNECOLOGIC HISTORY:
(-) Dyspareunia (-) Post Coital Bleeding
(-) Chronic Pelvic Pain (-) Foul-smelling discharge
(-) Postcoital bleeding

SEXUAL HISTORY:
First Sexual Contact: 17 years old
Number of Sexual Partners: 3
Contraceptive: none

JRRMMC-F-OBG-IIF-20 February 20, 2016 Revision No.: 0 Page 1 of 1


FORM NO. IIFb-26
Republic of the Philippines
Department of Health
JOSE R. REYES MEMORIAL MEDICAL CENTER
Department of Obstetrics and Gynecology

OBSTETRIC HISTORY:
LMP: 2015
PMP: N/A
Menoupause: 36 years old

G5P5 (5005)
Gravida Outcom Route Place BW Complica
Year e of tions
Birth
G1 - Male, Normal Rizal AGA None
1997 Term spontane provinc
alive ous ial
delivery Hospit RESIDENTS 24-HOUR OB-GYNE HISTORY
al DATE: December 6, 2016
G2 Female, Normal Rizal AGA None HOSPITAL NO.: 2016094313
2000 Term spontane provinc ATTENDING PHYSICIAN: Dr. Cuenca/ Alava/
alive ous ial Morante/ Naguit/ Beron, Donato/ Rodriguez
delivery Hospit -------------------------------------------------------------------------------
al -----
G3 Male, Normal Makati AGA None GENERAL DATA:
2001 Term spontane , Lying Name: Carmen, Stephanie Alba Age: 15 y/o
alive ous in
delivery Civil Status: Single Birthday: 08/13/2001
G4 Female, Normal Well AGA None Religion: Roman Catholic
2004 Term spontane Care Address: Tondo Manila
alive ous Family,
delivery CHIEF COMPLAINT: Labor pain
Lying
in
G5- Male, Cesarean Rizal AGA None HISTORY OF PRESENT ILLNESS:
2005 Term section provinc
alive ial 1st trimester:
Hospit The patient noted cessation of menstruation.
al Pregnancy test was done at home and it tested positive.
Patient started prenatal check-up and was given
PHYSICAL EXAMINATION: Multivitamins. Ultrasound was done. Negative for any
General Survey: Patient is conscious, coherent, and in maternal illness.
cardiorespiratory distress, with the following vital signs:
BP: 100/80mmhg CR: 99 RR: 27 T: 36.2oC 2nd Trimester:
HEENT: Anicteric sclera, pink palpebral conjunctiva, no Patient continued her prenatal check-up and
nasal and aural discharge, no tonsillopharyngeal continued above medications. Ultrasound was done. No
congestion, no cervical lymphadenopathy, no neck vein vomiting, nausea and vaginal bleeding. Noted good fetal
engorgement movement.
Chest and Lungs: Symmetrical chest expansion, no
retractions, with decreased breath sound on right lobe, 3rd Trimester:
no crackles or wheezes Patient continued her prenatal check-up and
Heart: Adynamic precordium, normal rate, regular continued above medications. nausea and vaginal
rhythm, no heaves, lifts, thrills, or presence of murmur, bleeding. Negative for any maternal illness.
apex beat located at 5th intercostal space midclavicular
line Few hours prior to admission, the patient noted
Breast: Symmetrical contour, no dimpling, no palpable vaginal bleeding accompanied by hypogastric pain.
mass, no tenderness, no abnormal nipple discharge Hence sought consult in our institution.
Abdomen: Flabby, soft, no tenderness noted upon
palpation, normoactive bowel sounds PAST MEDICAL HISTORY:
Extremities: grossly normal extremities, no (-) HPN (-) Heart Disease (-) Previous surgery
deformities, no cyanosis, no edema (-) DM (-) PTB (-) Thyroid disease
Skin: brown, warm to touch, moist, with good skin (-) Asthma (-) Liver Disease (-) Kidney
turgor, capillary refill <2 sec Disease

Speculum exam: not done FAMILY HISTORY:


(-) HPN (-) Thyroid disease (-) PTB
Internal examination: not done (-) DM (-) Heart Disease (-) Asthma
(-) Liver Disease (-) Kidney Disease
ASSESSMENT: Squamous Cell Carcinoma stage IIB, (-) Malignancy
Pleural effusion right
PERSONAL AND SOCIAL HISTORY:
PLAN: for chest tube thoracotomy c/o general surgery (-) Smoking
(-)Alcoholic beverage drinker

JRRMMC-F-OBG-IIF-20 February 20, 2016 Revision No.: 0 Page 1 of 1


FORM NO. IIFb-26
Republic of the Philippines
Department of Health
JOSE R. REYES MEMORIAL MEDICAL CENTER
Department of Obstetrics and Gynecology

(-) Illicit Drug Use ASSESSMENT: Gravida 1 Para 0 Pregnancy Uterine 38


(-) Allergy to food and drugs weeks 5/7 days Age of Gestation by Last Menstrual
Period, Cephalic in labor
Educational Attainment: College graduate
Employment: unemployed PLAN: for Normal Spontaneous Delivery

MENSTRUAL HISTORY:
Menarche: 12 years old
Interval: 28-30 days
Duration: 3 days
Amount: 3 pads per day, moderately soaked
Symptoms: (+) Dysmenorrhea

GYNECOLOGIC HISTORY:
(-) Dyspareunia (-) Post Coital Bleeding
(-) Chronic Pelvic Pain (-) Foul-smelling discharge
(-) Postcoital bleeding

SEXUAL HISTORY:
First Sexual Contact: 14
Number of Sexual Partners: 1
Contraceptive: Oral contraceptive none

OBSTETRIC HISTORY: RESIDENTS 24-HOUR OB-GYNE HISTORY


LMP: March 15, 2016 DATE: December 6, 2016
PMP: February 2016 HOSPITAL NO.: 2002010739
AOG: 38 weeks days ATTENDING PHYSICIAN: Dr. Cole/ Cartagena/
EDC: December 20, 2016 Morante/ Naguit/ Beron, Donato/ Rodriguez
-------------------------------------------------------------------------------
G1P0 -----
Gravida Outcom Route Place BW Complicati GENERAL DATA:
Year e of ons Name: Enriquez, Loida Age: 59 year old
Birth Civil Status: Married Birthday: January 11,
G1 Present 1959
2016 Pregnan Religion: Roman Catholic
cy Address: Caloocan City

PHYSICAL EXAMINATION: CHIEF COMPLAINT: vaginal pain


General Survey: Patient is conscious, coherent, and not
in cardiorespiratory distress, with the following vital HISTORY OF PRESENT ILLNESS:
signs:
BP: 100/60mmhg CR: 84 RR: 18 T: 36.5oC Patient is a known case of pelvic organ prolapse
HEENT: Anicteric sclera, pink palpebral conjunctiva, no stage IV with cystoceole.
nasal and aural discharge, no tonsillopharyngeal Few hours prior to consult, the patient
congestion, no cervical lymphadenopathy, no neck vein experienced vaginal pain due to the protusion of the
engorgement tissue at the front wall of the vagina, associated with
Chest and Lungs: Symmetrical chest expansion, no vaginal bleeding (spotting), dysuria and constipation.
retractions, with clear breath sound, no crackles or Due to persistence of symptoms, patient sought consult
wheezes in Gyne-Onco opd, was admiited and was advised to do
Heart: Adynamic precordium, normal rate, regular suegery.
rhythm, no heaves, lifts, thrills, or presence of murmur,
apex beat located at 5th intercostal space midclavicular PAST MEDICAL HISTORY:
line (+) HPN (-) Heart Disease (-) Previous surgery
Breast: Symmetrical contour, no dimpling, no palpable (-) DM (-) PTB (-) Thyroid disease
mass, no tenderness, no abnormal nipple discharge (-) Asthma (-) Liver Disease (-) Kidney
Abdomen: Globular, soft, no tenderness noted upon Disease
palpation, normoactive bowel sounds
FH: 25 FAMILY HISTORY:
FHT: 138 (-) HPN (-) Thyroid disease (-) PTB
(+) DM (-) Heart Disease (-) Asthma
LM1: Breech LM3: cephalic (-) Liver Disease (-) Kidney Disease
LM2: Fetal back maternal right LM4: not engaged (-) Malignancy

Extremities: grossly normal extremities, no PERSONAL AND SOCIAL HISTORY:


deformities, no cyanosis, no edema (-) Smoking
Skin: brown, warm to touch, moist, with good skin (-)Alcoholic beverage drinker
turgor, capillary refill <2 sec (-) Illicit Drug Use
SPECULUM EXAM: Cervix smooth, violaceous (-) Allergy to food and drugs
INTERNAL EXAMINATION: Cervix 4 cm dilated,
Beginning Effecement, Intact Bag of Water, Cephalic, Educational Attainment: Grade 6 level
Station -3 Employment: unemployed

JRRMMC-F-OBG-IIF-20 February 20, 2016 Revision No.: 0 Page 1 of 1


FORM NO. IIFb-26
Republic of the Philippines
Department of Health
JOSE R. REYES MEMORIAL MEDICAL CENTER
Department of Obstetrics and Gynecology

Internal examination: not done


MENSTRUAL HISTORY:
Menarche: 13 years old ASSESSMENT:Gravida 4 Para 3 (3013) Pelvic Organ
Interval: 28-32 days Prolapse stage IV with cystocoele
Duration: 5-6 days
Amount: 3 pads per day, fully soaked PLAN: For Vaginal Hysterectomy, Kelly plication, Anterior
Symptoms: (-) Dysmenorrhea Posterior repair

GYNECOLOGIC HISTORY:
(-) Dyspareunia (-) Post Coital Bleeding
(-) Chronic Pelvic Pain (-) Foul-smelling discharge
(-) Postcoital bleeding

SEXUAL HISTORY:
First Sexual Contact: 19 year old
Number of Sexual Partners: 1
Contraceptive: Oral contraceptive none

OBSTETRIC HISTORY:
LMP: June, 2016
PMP: May 2016
Menoupause: N/A

G4P3 (3013)
Gravida Outcom Route Place BW Complicati
Year e of ons
Birth
G1 - Abortio
1978 n
G2 Male, NSD MCU AGA None
1979 Term
alive
G3 Male, QCGH Lying AGA None
1980 Term -In
alive
G4 Male, QCGH Home AGA None
1982 Term Deliv
alive ery

PHYSICAL EXAMINATION:
General Survey: Patient is conscious, coherent, and not
in cardiorespiratory distress, with the following vital
signs:
BP: 140/90mmhg CR: 79 RR: 19 T: 36.5oC
HEENT: Anicteric sclera, pink palpebral conjunctiva, no
nasal and aural discharge, no tonsillopharyngeal
congestion, no cervical lymphadenopathy, no neck vein
engorgement
Chest and Lungs: Symmetrical chest expansion, no
retractions, with clear breath sound, no crackles or
wheezes
Heart: Adynamic precordium, normal rate, regular
rhythm, no heaves, lifts, thrills, or presence of murmur,
apex beat located at 5th intercostal space midclavicular
line
Breast: Symmetrical contour, no dimpling, no palpable
mass, no tenderness, no abnormal nipple discharge
Abdomen: Globular, soft, no tenderness noted upon
palpation, normoactive bowel sounds

Extremities: grossly normal extremities, no


deformities, no cyanosis, no edema
Skin: brown, warm to touch, moist, with good skin
turgor, capillary refill <2 sec

Speculum exam: not done

JRRMMC-F-OBG-IIF-20 February 20, 2016 Revision No.: 0 Page 1 of 1