Name of Patient: Rika Narbonita Department: Obstetrics and

Informant: Patient Gynecology

Reliability: Good (90%) Preceptor: Dr. Labios
Historian: Elardo. Salvatore Juliano M. Date Taken: September 10, 2018
Section and Group: 18B Date Submitted: September 17, 2017
Hospital: DLSUMC

OBSTETRICS HISTORY
GENERAL DATA
RN, 27 years old, G2P1 (1001), Married, Filipino, Roman Catholic, born on August 7, 1990 at Carmona,
Cavite, currently residing in GMA, Cavite, consulted at DLSUMC for 6th time on September 10, 2018 at 2:30
PM.

CHIEF COMPLAINT: Prenatal check-up

PAST MEDICAL/SURGICAL HISTORY

The patient has no history of allergies, hepatitis, thyroid disorders, cardiac problems, sexually
transmitted infections, hypertension, cancer, tuberculosis, and renal problems. There is no history of surgery
or past hospitalizations not related to gynecological procedures. Patient has complete vaccinations. Patient
is blood type B+ and her husband blood type A+.

FAMILY HISTORY
The patient has a history of Diabetes Mellitus and asthma on her father’s side. Her father also has
been diagnosed with TB during 2003, was treated for 2 years, and is now free of TB.

PERSONAL AND SOCIAL HISTORY

Patient finished vocational studies in IT and used to work at Jollibee but has resigned. She now
relies on her husband’s income. Patient does not smoke, drink alcohol or consume illicit drugs. Her husband
had also studied vocational IT and does not smoke but drinks occasionally. Her usual everyday activities
include chores and taking care of her son. Their household water is sourced from the water district and use
mineral water for drinking. Trash is collected every Wednesday and they use gas for cooking. Patient lives
in a bungalow type household near the highway with her husband and 5 year old son.

MENSTRUAL HISTORY
Patient started her menarche at the age of 12. Her cycle occurs regularly every month and lasts at for 3 to
5 days, consuming 2 slightly soaked pads per day. There were no accompanying dysmenorrhea, dizziness,
or headache. Patient did not use any medication.

OBSTETRICAL HISTORY: Patient is G2P1 (1001)

Patient had CS during her first pregnancy and had an incidental finding of appendicitis hence the
appendectomy.

Number of Date AOG Manner of Place of Sex Birth Present Complication

Pregnancies Delivery
Delivery/Attendant Weight Status
at Birth
G1 October 40 CS with DLSUMC F 3.5 Yes None
5, weeks appendectomy kilos
2013 (Primary)
GYNECOLOGICAL HISTORY
Patient has no history of gynecological complications. She underwent Pap smears during 2018 with
normal results. She has not had surgeries or infections.

SEXUAL HISTORY
Patient's coitarche was at 22 years old. She has 1 sexual partner and has coitus twice a month
with her husband. She is sexually satisfied and has no post coital bleeding or dyspareunia noted. Last
sexual contact was unrecalled.

CONTRACEPTIVE HISTORY
Patient used unrecalled OCP after her first pregnancy (2013) for one year and stopped due to side
effects of increased irritability and headaches.

HISTORY OF PRESENT PREGNANCY

LNMP: January 17, 2018
EDC: 1st three weeks of October, 2018
AOG: 33 weeks and 5 days
Quickening: 4 months

IMMUNIZATIONS:
Patient has had tetanus vaccines only, 5 months prior to consult.

REVIEW OF SYSTEMS
General (-) weakness (-) loss of appetite (-) weight loss (+) weight gain (-) easy fatigability
Integument (-) rashes (-) pruritus (+) hyperpigmentation (+) stretch marks
HEENT (-) headache (-) dizziness (-) vision difficulties (-) corrective lenses (-) hearing difficulties (-)
frequent colds (-) nasal discharge (-) epistaxis (-) toothache (-) lymphadenopathy (-)
stiffness
Respiratory (-) cough (-) dyspnea

Cardiovascular (-) angina (-) palpitations (-) cyanosis (-) orthopnea (-) fainting spells
GIT (-) melena (-) hematochezia (-) melena (-) abdominal pain (-) nausea and vomiting

GUT (-) polyuria (-) nocturia

Hematologic (-) easy bruising

MSS/ (-) cramps at night (-) edema
Extremities
Nervous System (-) headache

Endocrine (-) polyphagia (-) polyuria (-) polydipsia (-) cold intolerance (-) heat intolerance

EXAMINATION

GENERAL SURVEY:
Patient well developed, well nourished, conscious, coherent, ambulant, oriented to time, place and person,
not in cardio-respiratory distress and appears her chronological age of 27.

VITAL SIGNS:
BP= 100/70 mmHg, sitting, right and left arm
 Pre pregnancy weight= 50 kg
HR= 90 Present weight= 72 kg
PR= 84 Height= 154.94 cm
RR= 20 BMI=
Temp= 36.5 C

HEENT
Patient has normal even skin color; eyes were symmetrical, intact pupillary reflex, (-) nystagmus; No
lesions, deformities masses, or tenderness in the periauricular area, ear canal is patent and devoid of
masses with scanty cerumen, tympanic membrane on both ears are intact, pearly gray, shiny, translucent,
and devoid of any discharge or masses; nose was symmetrical; Pink symmetrical lips with no masses or
ulcerations. There were no thyroid enlargements palpated and non-palpable lymph nodes.

CHEST AND LUNGS

Chest wall is symmetrical, no deformities.No associated extra-pulmonary findings like clubbing, facial
puffiness and prominent veins.

BREASTS (not assessed)

HEART:
Patient has regular rhythm.

ABDOMEN:
Inspection: Patient has a globular enlarged abdomen. A midline, hypertrophic scar from her past CS
pregnancy is seen above the symphysis pubis, measuring 28 cm and 2 cm maximum width. Light and thin
striae can be seen at the right and left flanks of the abdomen. The umbilicus is also hyper pigmented and
flat.

Palpation:
FH= 29cm
LM1: breech
LM2: Fetal back on maternal left
LM3: head is not engaged, cephalic presentation
LM4: unengaged
FHT: 150 bpm

GENITALIA (not done)

EXTREMITIES
No edema on all extremities. Good muscle tone. No quadriplegia or quadriparesis. No redness, mass,
swelling, nor tenderness. Deformity, atrophy, crepitus, limitation of motion in the upper and lower
extremities.

NEUROLOGIC: if warranted

Mental Status: Patient is awake, cooperative to the examiner, oriented to time, place, and person, is
dressed appropriately according to age and occasion, with normal stream of talk, appropriate mood and
thought content.

Cranial Nerves (not done)

Sensory (not done)
Cerebellar (not done)
Meningeals (not done)
Higher Cerebral Functions (not done)
IMPRESSION:

27 years old, G2P1 (1001), 33 weeks and 5 days AOG, cephalic presentation, not in labor,

Risk Factor: Previous CS

Management:
Continue prenatal visits every week until time of delivery
Advise the different danger signs of pregnancy, if any signs are present, consult obstetrician immediately.
Advise to complete immunizations: recommended to take are tetanus toxoid, influenza, and
pneumococcal
Advise to continue religious intake of multivitamins and iron supplement until her obstetrician decides to
end her medication in preparation for her nearing delivery
Educate of postpartum care and benefits of breastfeeding
Educate the patient on the signs of labor and how to prepare for when time of delivery comes
Advise patient to seek admission before labor begins to prepare for probable complications during
delivery/CS delivery