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Form No. Iifb-26: Pandacan, Manila

The document contains a resident's 24-hour obstetrics and gynecology history for a 24-year-old female patient who presented with epigastric pain, bloatedness, fever, nausea, and vomiting. The patient's vital signs and physical exam results are documented. The assessment is for a Gravida 1 Para 1 patient with a past medical history notable for squamous cell carcinoma.

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Aileen Emy
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37 views

Form No. Iifb-26: Pandacan, Manila

The document contains a resident's 24-hour obstetrics and gynecology history for a 24-year-old female patient who presented with epigastric pain, bloatedness, fever, nausea, and vomiting. The patient's vital signs and physical exam results are documented. The assessment is for a Gravida 1 Para 1 patient with a past medical history notable for squamous cell carcinoma.

Uploaded by

Aileen Emy
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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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

RESIDENT’S 24-HOUR OB-GYNE HISTORY Gravid 1 Para 1 (1001)


DATE: August 11, 2019 GRAVITY OUTCOME ROUTE PLACE OF BIRTH COMPLI
HOSPITAL NO.: 2019058338 YEAR DELIVERY WEIGHT CATIONS
ATTENDING PHYSICIAN: Dr. Cole/ Mercadal, Rivera/ Abrenica, De G1 Live, Term, NSD Ospital ng unrecalled None
2012 Boy Maynila
Leon/ Parocco, Yu
------------------------------------------------------------------------------------
GENERAL DATA: PHYSICAL EXAMINATION:
Name: FEDERIO, MARY ANN Age: 24 years old General Survey: Patient is conscious, coherent, not in cardiorespiratory
Civil Status: Single Birth date: August 21, 1994 distress with the following vital signs
Religion: Catholic BP: 110/70mmHG CR:80bpm RR:18 cpm T:39.1 C
Address: Pandacan, Manila HEENT: Anicteric sclera, pale palpebral conjunctiva, no nasal and aural
discharge, no tonsillopharyngeal congestion, no cervical
CHIEF COMPLAINT: lymphadenopathy, no neck vein engorgement.
Epigastric Pain Chest and Lungs: Symmetrical chest expansion, no retractions, with
clear breath sounds
HISTORY OF PRESENT ILLNESS Heart: Adynamic precordium, normal rate, regular rhythm, no murmur
7 hours prior to admission, patient noted epigastric pain, Abdomen: Flat, normoactive bowel sounds, (-)tenderness
8/10, associated with bloatedness, fever, nausea and vomiting. No Speculum Exam: Not Done
dysuria and constipation was noted. Patient took buscopan tablet which Internal Exam: Not Done
afforded no relief. Persistence of symptoms prompted consult. Extremities: Grossly normal extremities, no deformities, no cyanosis, no
edema
PAST MEDICAL HISTORY:
(-) HPN (-) Asthma ASSESSMENT: Gravida 1 Para 1 (1001) Squamous Cell Carcinoma, Large
(-) Heart disease (-) Thyroid disease Cell, Non-keratinizing, Stage IIB
(-) DM (-) Liver Disease
(-) PTB (-) Kidney Disease PLAN: For Medical Management
(-) Previous Operation

FAMILY HISTORY:
(-) Malignancy (-) Asthma
(-) HPN (-) Liver disease
(+) Heart Disease, paternal (-) Kidney disease
(-) DM (-) Malignancy
(-) PTB (-) Thyroid Disease

PERSONAL AND SOCIAL HISTORY:


(+) Smoker
(+) Alcoholic beverage drinker, occasional
(-) Illicit drug use
(-) Allergy to food
(-) Allergy to drugs

Educational Attainment: High School Graduate


Employment: None

MENSTRUAL HISTORY:
Menarche: 15 years old
Interval: Regular
Duration: 7 days
Amount: 4 pads/day, fully soaked
Symptoms: (-) dysmenorrhea

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

SEXUAL HISTORY:
First Sexual Contact: 16 years old
Number of Sexual Partners: 2
Contraceptive: None

OBSTETRIC HISTORY:
LMP: July 20, 2019
PMP: June 19, 2019

JRRMMC-F-OBG-IIF-20 August 3, 2016 Revision No.: 0 Page 1 of 1

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