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 17, 2016 G1P0
HOSPITAL NO.: 201 Gravida Outcom Route Place BW Complicati
ATTENDING PHYSICIAN: Dr. Queveda Year e of ons
------------------------------------------------------------------------------- Birth
----- G1 Present Pregnancy
GENERAL DATA: (2016)
Name: Rosero, Joan Dapla Age: 18 years old
Civil Status: Single Birthday: February PHYSICAL EXAMINATION:
1994 General Survey: Patient is conscious, coherent, not in
Religion: Roman Catholic Address: Quezon City cardiorespiratory distress
BP: 100/60mmhg CR: 78 RR: 20 T: 36.4oC
CHIEF COMPLAINT: Watery vaginal discharge HEENT: Anicteric sclera, pink palpebral conjunctiva, no
nasal and aural discharge, no tonsillopharyngeal
HISTORY OF PRESENT ILLNESS: congestion, no cervical lymphadenopathy, no neck vein
1st trimester: engorgement
The patient noted cessation of menstruation. Chest and Lungs: Symmetrical chest expansion, no
Pregnancy test was done at home which tested positive. retractions, with clear breath sound, no wheezes, no
No prenatal check-up was done. No medication taken. crackles
Negative for any maternal illness. Heart: Adynamic precordium, normal rate, regular
rhythm, no heaves, lifts, thrills, or presence of murmur,
2nd Trimester apex beat at 5th intercostal space midclavicular line
Patient had prenatal check-up at ____ prescribed Breast: Symmetrical contour, no dimpling, no palpable
drugs were Multivitamins, Folic acid and Ferrous sulfate. mass, no tenderness, no abnormal nipple discharge
Negative for any maternal illness. Abdomen: Flabby, no tenderness noted upon palpation,
. normoactive bowel sounds.
Few hours prior to consultation patient FH: 21 cm FHT: N/A
experienced vaginal bleeding with passage of meaty LM1: LM3:
tissue, which prompted the patient to sought consult and LM2: LM4:
was subsequently admitted. SPECULUM EXAMINATION:
Speculum examination: Not done
PAST MEDICAL HISTORY: Internal examination:
(-) HPN (-) Heart Disease (-) Previous surgery Cervix: fully dilated, fully effaced
(-) DM (-) PTB (-) Asthma Corpus: ruptured bag of water, Station -3
(-) 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 ASSESSMENT: Gravida 1 Para (0010) incomplete
(-) Malignancy abortion 14 2/7 weeks age of gestation by last menstrual
period, Non-septic non-induced- completed s/p
PERSONAL AND SOCIAL HISTORY: completion curettage
(-) Smoking
(-)Alcoholic beverage drinker PLAN: For completion curettage
(-) Illicit Drug Use
(-) Allergy to food and drugs

Educational Attainment: High school graduate

Employment: Unemployed

MENSTRUAL HISTORY:
Menarche: 13 years old
Interval: 28-30 days
Duration: 3 days
Amount: 3 pads per day; fully soaked
Symptoms: (-) Dysmenorrhe

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: None

OBSTETRIC HISTORY:
LMP: September 6, 2016
PMP: August 7, 2016
AOG: 14 2/7 weeks by last menstrual period
EDC: ___

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

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