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Name: KNEDRICK KEVIN C.

MACALMA Course/Year: DOCTOR OF MEDICINE III

Subject: OBSTETRICS Professor: DR. FERRARIS

Date and Time: September 5, 2017 at 10:30 AM

Place: Out Patient Department OB

Source of Information: Patient

Reliability: Patient gives same answers to the question even when verified; Very reliable (100%)

GENERAL DATA

Michelle M. Salud is a 28 year old Filipino female, Roman Catholic, married, born on March 21, 1989 in
MMMH&MC and is currently residing at Brgy. Bungon, City of Batac, Ilocos Norte. She is currently
unemployed. She is affiliated to Pentecost.

CHIEF COMPLAINT

Prenatal Check Up

HISTORY OF THE PRESENT ILLNESS

LMP: October 18, 2016


PMP: August 23, 2016
AOG: 38 3/7 via ultrasound
EDC: September 30, 2017

PRENATAL HISTORY

The patient was cognizant of her pregnancy at 8 weeks AOG through a positive pregnancy test done at
home. She claims that her pregnancy was unplanned without attempts of abortion. Her first prenatal
check-up was done at 12 weeks AOG at a private OB-gyne clinic.

Associated symptoms of her pregnancy are feeling of dizziness and urinary disturbances. At 5th month
AOG, patient sleeping pattern changed from 1:00 PM-5:00 AM to 1:30 AM - 6:30 AM because she is
experiencing nocturia 5 times every night.

The patient was advised to take Neurovit forte and ferrous sulfate during the course of her pregnancy
together with monthly prenatal checkup.

There was no reported exposure to viral exanthematous diseases like measles and chiken pox, radiation,
and toxic chemicals. There was no history of alcohol and illicit drug intake and cigarette smoke
exposure.
OB-GYNE History

A. Menstrual history

Menarche was at 13 years old with 5 to 7 days duration, consuming an average of 3-4 fully soaked
pads/day with associated dysmenorrheal. Subsequent menses occurred irregularly lasting an average of
5 days consuming 2-3 fully soaked pads per day with associated dysmenorrheal. No medication was
taken to relieve the pain.

B.OB score

G2P1 (1-0-0-1)

GRAVIDA DATE OF INSTITUTION MANNER OF SEX Complica TERM WEIGHT


DELIVERY DELIVERY tion
G1 January 5, 2015 MMMH&MC Caesarian section- Male None TERM 2.5 kg
due to breech
presentation

C. Gynecologic History

There was no history of gynecologic disease such as vaginal discharges or sexually transmitted diseases.
There was no history of surgical procedure aside from the caesarean section last 2015. At her 4th month
AOG she is found out to have UTI, medications were given to her but specific name of the drug was
unrecalled. No noted hormonal therapy, Pap smear procedure was done to her. The patient took did not
take any oral contraceptive pills nor use any other form of contraception.

D. Sexual History

The patient had her first sexual contact when she was 23 years old with no associated bleeding and
dyspareunia. She has one sexual partner. She has 2-year-old child with her partner. The patient also
admits that they do not have problems with their sexual activity.

PAST MEDICAL HISTORY

Patient was born via NSVD at MMMH&MC. The patient has no history of any medical illnesses, which
required hospitalization. She has no known allergies to food or drugs.

The patient remembers she had immunization when she was a child this includes VZV, MMR, BCG, OPV
and DPT. Childhood diseases includes chickenpox, measles and mumps. At year 1997 she had dengue
fever, which she is being transfused, number of blood bags was unrecalled by the patient. No noted
major accidents and trauma.

FAMILY HISTORY

Patient is the 3rd child among her 3 siblings, both parents are still alive and in a good state of
health. Her father has hypertension. Her eldest brother died of car accident at Saudi last 1997. Her
sister is currently working in Taiwan as a nurse. Her youngest sister works as a nurse in Saudi. Her
mother has asthma. Other than hypertension and asthma there are no noted heredofamilial disorders
like DM, cancer and arthritis.

SOCIAL AND ENVIRONMENTAL HISTORY

The patient is currently unemployed. She is a graduate of Data Center as a Computer Secretary
and finished only up to 3rd year Commerce at University of Cordillera. From 2005-2010 she worked as a
factory worker in Taiwan.
The patient lives in a 2-storey house with 3 rooms and 2 occupants with her family. The patient diet
consisted of large intake of fruits, vegetables and rice with a minimal amount of meat. She is fond of
drinking Coke. The source of water for domestic purposes is coming from a Baguio Water District and
the water for drinking is from a water refilling station. Garbage is properly segregated and is collected
regularly every Saturday. The patient is a nonsmoker and nonalcoholic beverage drinker. They have no
pets. The toilet is flush type.

REVIEW OF SYSTEMS
General: (-) weakness, (-) fever, (-) pallor, (-) fatigue, (-) nausea, (+) weight gain from 53 kg to 152 lbs.
Integument: (-) pigmentation, (-) rashes, (-) edema
Head and Neck: (+) headache, (-)swelling, (-) stiffness
Eyes: (-) blurring of vision, (-) redness, (-) pain, (-) itch, (-) excessive tearing
Nose and sinuses: (-) bleeding, (-) discharge, (-) colds,
Mouth: (-) pain, (-) soreness, (-) swelling
Breast: (-) discharges, (-) pain, (-) lump
Respiratory: (-) cough, (-) pain, (-) dyspnea
Cardiac: (-) angina, (-) palpitations, (-) dyspnea
Gastrointestinal: (-) vomiting , (-) nausea, (-) abdominal pain, (-) diarrhea, (-) constipation, (-) anorexia, (-
) change in bowel habits
Renal and Urinary: (-) dysuria, (-) incontinence, (+) frequency 3x every night
Musculoskeletal: (-) edema, (-) pain, (-) tenderness, (-) weakness, (-) trauma, (-) stiffness
Hematological: (-) anemia, (-) bruising
Endocrine: (-) polyphagia, (+) polyuria, (-) heat/cold intolerance, (-) profuse sweating, (-) loss of appetite
Nervous System: (-) syncope, (-) dizziness, (-) motor problems
Emotional: (-) anxiety, (+) sleep disturbances, (-) depression
Gynecologic: (-) vaginal discharge, (-) spotting, (-) dyspareunia, (+) dysmenorrheal