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Form No. Iifb-26: Republic of The Philippines Department of Health Department of Obstetrics and Gynecology

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Aileen Emy

This document is a medical record summarizing a 19-year-old female patient's obstetric and gynecological history and current admission to the hospital. She presented with difficulty breathing for 3 days and was assessed to have community-acquired pneumonia. Her medical history includes a previous full-term spontaneous vaginal delivery. On examination, she had decreased breath sounds in her right lower lung and was assessed to have community-acquired pneumonia of moderate risk. The treatment plan was for medical management.

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Form No. Iifb-26: Republic of The Philippines Department of Health Department of Obstetrics and Gynecology

Uploaded by

Aileen Emy
24 views1 page
This document is a medical record summarizing a 19-year-old female patient's obstetric and gynecological history and current admission to the hospital. She presented with difficulty breathing for 3 days and was assessed to have community-acquired pneumonia. Her medical history includes a previous full-term spontaneous vaginal delivery. On examination, she had decreased breath sounds in her right lower lung and was assessed to have community-acquired pneumonia of moderate risk. The treatment plan was for medical management.

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ob maulit

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Ob Maulit, Shabie

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This document is a medical record summarizing a 19-year-old female patient's obstetric and gynecological history and current admission to the hospital. She presented with difficulty breathing for 3 days and was assessed to have community-acquired pneumonia. Her medical history includes a previous full-term spontaneous vaginal delivery. On examination, she had decreased breath sounds in her right lower lung and was assessed to have community-acquired pneumonia of moderate risk. The treatment plan was for medical management.

Copyright:

© All Rights Reserved
Download as DOCX, PDF, TXT or read online from Scribd
Download as docx, pdf, or txt
24 views1 page

Form No. Iifb-26: Republic of The Philippines Department of Health Department of Obstetrics and Gynecology

Uploaded by

Aileen Emy
This document is a medical record summarizing a 19-year-old female patient's obstetric and gynecological history and current admission to the hospital. She presented with difficulty breathing for 3 days and was assessed to have community-acquired pneumonia. Her medical history includes a previous full-term spontaneous vaginal delivery. On examination, she had decreased breath sounds in her right lower lung and was assessed to have community-acquired pneumonia of moderate risk. The treatment plan was for medical management.

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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 OBSTETRIC HISTORY:


DATE: August 11, 2019 LMP: October 31, 2018
HOSPITAL NO.: 2019072671 PMP: September 30, 2018
ATTENDING PHYSICIAN: Dr. Valencia/ Cuenco, Corpuz/ FULE/
Magdaluyo, Perez/ Cabana, Cariño Gravida 1 Para 1 (1001)
------------------------------------------------------------------------------------ GRAVITY OUTCOME ROUTE PLACE OF BIRTH COMPLICATIONS
YEAR DELIVERY WEIGHT
GENERAL DATA:
G1 Live, term, NSD Ospital ng 3100 g None
Name: MAULIT, SHABIE Age: 19 years old 2019 male Tondo
CORDOVA
Civil Status: Single Birth date: February 27, 2000
Religion: Catholic PHYSICAL EXAMINATION:
Address: 1110 Morong St. Tondo, Manila General Survey: Patient is conscious, coherent, not in
cardiorespiratory distress with the following vital signs
CHIEF COMPLAINT: BP: 110/70mmHG CR: 98 bpm RR: 24 cpm T: 37.0 C
Difficulty breathing HEENT: Anicteric sclera, pink palpebral conjunctiva, no nasal and aural
discharge, no tonsillopharyngeal congestion, no cervical
HISTORY OF PRESENT ILLNESS lymphadenopathy, no neck vein engorgement
Three days prior to admission, patient noted difficulty Chest and Lungs: Symmetrical chest expansion, no retractions, with
breathing associated with cough. No noted fever. No medications decreased breath sounds right lower lung field
taken. No consult sought. Heart: Adynamic precordium, normal rate, regular rhythm, no murmur
Few hours prior to admission, patient still had persistence Abdomen: Flabby, normoactive bowel sounds, no tenderness
of symptoms. patient sought consult at Ospital ng Tondo and was Speculum Exam: Cervix pinkish in color, no lesions, (+) scanty bleeding
assessed G1P1 (1001) Post NSD Day to consider Congestive Heart Internal Exam: Cervix soft and closed, (+) lochial discharge, corpus
Failure, Community-Acquired Pneumonia. Patient was then advised to enlarged to 3 months size, no adnexal masses
transfer to another institution for further evaluation and management Extremities: Grossly normal extremities, no deformities, no cyanosis,
no edema
PAST MEDICAL HISTORY:
(-) HPN (-) Thyroid disease ASSESSMENT:
(-) Heart disease (-) Liver disease Gravida 1 Para 1 (1001) Pregnancy Uterine Term, Cephalic Delivered
(-) DM (-) Kidney disease Spontaneously to a Live Baby Boy; Community-Acquired Pneumonia –
(-) PTB (-) Prev operation Moderate Risk
(-) Asthma
PLAN:
For Medical Management
FAMILY HISTORY:
(-) Malignancy (+) Asthma – paternal
(-) HPN (-) Thyroid disease
(-) Heart Disease (-) Liver disease
(-) DM (-) Kidney disease
(-) PTB

PERSONAL AND SOCIAL HISTORY:


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

Educational Attainment: Grade 8


Employment: None

MENSTRUAL HISTORY:
Menarche: 13 years old
Interval: 28-30 days
Duration: 3-4 days
Amount: 2-3 pads per day, moderately 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: 5
Contraceptive: None

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

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