Professional Documents
Culture Documents
IIFb-26
Republic of the Philippines
Department of Health
JOSE R. REYES MEMORIAL MEDICAL CENTER
Department of Obstetrics and Gynecology
MENSTRUAL HISTORY:
Menarche: 11 years old
Interval: 28-30 days
Duration: 4-5 days
Amount: 3 pads per day, moderately soaked
Symptoms: (-) Dysmenorrhea
GYNECOLOGIC HISTORY:
(-) Dyspareunia (-) Post Coital Bleeding
(-) Chronic Pelvic Pain (-) Foul-smelling discharge
(-) Postcoital bleeding
MENSTRUAL HISTORY:
Menarche: 12 years old
Interval: 28-30 days
Duration: 5 days
Amount: 4 pads per day, moderately soaked
Symptoms: (+) Dysmenorrhea
apex beat located at 5th intercostal space midclavicular PAST MEDICAL HISTORY:
line (-) HPN (-) Heart Disease (-) Previous surgery
Breast: Symmetrical contour, no dimpling, no palpable (-) DM (-) PTB (-) Thyroid disease
mass, no tenderness, no abnormal nipple discharge (-) Asthma (-) Liver Disease (-) Kidney
Abdomen: Globular, soft, no tenderness noted upon Disease
palpation, normoactive bowel sounds
FAMILY HISTORY:
Extremities: grossly normal extremities, no (-) HPN (-) Thyroid disease (-) PTB
deformities, no cyanosis, no edema (-) DM (-) Heart Disease (-) Asthma
Skin: brown, warm to touch, moist, with good skin (-) Liver Disease (-) Kidney Disease
turgor, capillary refill <2 sec (-) Malignancy
Speculum exam: cervix is closed with minimal bleeding PERSONAL AND SOCIAL HISTORY:
(-) Smoking
Internal examination: (-)Alcoholic beverage drinker
(-) Illicit Drug Use
ASSESSMENT: Squamous Cell Carcinoma, Stage IIIB (-) Allergy to food and drugs
MENSTRUAL HISTORY:
Menarche: 13 years old
Interval: Irregular
Duration: 3-4 days
Amount: 3 pads per day, moderately soaked
Symptoms: (-) Dysmenorrhea
GYNECOLOGIC HISTORY:
(-) Dyspareunia (-) Post Coital Bleeding
(-) Chronic Pelvic Pain (-) Foul-smelling discharge
(-) Postcoital bleeding
congestion, no cervical lymphadenopathy, no neck vein (-) DM (-) Heart Disease (-) Asthma
engorgement (-) Liver Disease (-) Kidney Disease
Chest and Lungs: Symmetrical chest expansion, no (-) Malignancy
retractions, with clear breath sound, no crackles or
wheezes PERSONAL AND SOCIAL HISTORY:
Heart: Adynamic precordium, normal rate, regular (-) Smoking
rhythm, no heaves, lifts, thrills, or presence of murmur, (-)Alcoholic beverage drinker
apex beat located at 5th intercostal space midclavicular (-) Illicit Drug Use
line (-) Allergy to food and drugs
Breast: Symmetrical contour, no dimpling, no palpable
mass, no tenderness, no abnormal nipple discharge Educational Attainment: High school graduate
Abdomen: Globular, soft, no tenderness noted upon Employment: unemployed
palpation, normoactive bowel sounds
FH: 30 MENSTRUAL HISTORY:
FHT: 140s Menarche: 12 years old
Interval: 30 days
LM1: Breech LM3: cephalic Duration: 3 days
LM2: Fetal back maternal right LM4: engaged Amount: 3 pads per day, moderately soaked
Symptoms: (+) Dysmenorrhea
Extremities: grossly normal extremities, no
deformities, no cyanosis, no edema GYNECOLOGIC HISTORY:
Skin: brown, warm to touch, moist, with good skin (-) Dyspareunia (-) Post Coital Bleeding
turgor, capillary refill <2 sec (-) Chronic Pelvic Pain (-) Foul-smelling discharge
SPECULUM EXAM: Cervix smooth, violaceous (-) Postcoital bleeding
INTERNAL EXAMINATION: Cervix 7 cm dilated, 80%
Effacement, Ruptured Bag of Water, Cephalic, Station -2 SEXUAL HISTORY:
ASSESSMENT: Gravida 6 Para 3 Pregnancy Uterine 40 First Sexual Contact: 15 year old
weeks Age of Gestation by Last Menstrual Period, Number of Sexual Partners: 1
Currently in Labor. Contraceptive: Oral contraceptive none
G8P8 (8008)
Gravida Outcom Route Place BW Complicati
Year e of ons
Birth
G1 - Male, NSD Tond AGA None
1988 Term o Complicati
RESIDENTS 24-HOUR OB-GYNE HISTORY alive Gene on
DATE: December 6, 2016 ral
HOSPITAL NO.: 2016014902 Hospi
ATTENDING PHYSICIAN: Dr. ta
Bagadiong/Brazal/Soriano/Barcial/ Villanueva G2 Female, NSD Home AGA None
------------------------------------------------------------------------------- 1989 Term deliv Complicati
----- alive ery on
GENERAL DATA: G3 Female, NSD Home AGA None
Name: Adeva, Maria Luz Age: 50 year old 1990 Term deliv Complicati
Civil Status: Single Birthday: February 6, alive ery on
1966 G4 Female, NSD Tond AGA None
Religion: Roman Catholic 1991 Term o Complicati
Address: Manila alive Gene on
ral
CHIEF COMPLAINT: Difficulty of Breathing Hospi
tal
G5 Male NSD Tond AGA None
HISTORY OF PRESENT ILLNESS:
1992 Term o
alive Gene
Patient is a known case of cervical cancer stage
ral
IIIB last January 2016.
Hospi
Few hours prior to consult, the patient
tal
experienced difficulty of breathing associated with
G6 - Male NSD Tond AGA None
hypogastric pain. Due to persistence of symptoms,
1999 Term o
patient was brought to our institution.
alive Gene
ral
PAST MEDICAL HISTORY:
Hospi
(-) HPN (-) Heart Disease (-) Previous surgery
tal
(-) DM (-) PTB (-) Thyroid disease G7- Female NSD Tond AGA None
(-) Asthma (-) Liver Disease (-) Kidney 2000 Term o
Disease alive Gene
ral
FAMILY HISTORY: Hospi
(-) HPN (-) Thyroid disease (-) PTB tal
OBSTETRIC HISTORY:
LMP: June, 2016
PMP: May 2016
Menoupause: N/A
MENSTRUAL HISTORY:
Menarche: 16 years old
Interval: 38-32 days
Duration: 3-5 days
Amount: 3 pads per day, moderately soaked
Symptoms: (+) Dysmenorrhea
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: Oral contraceptive none
OBSTETRIC HISTORY:
LMP: June, 2016
PMP: May 2016
Menoupause: N/A
G4P4 (4004)
Gravida Outcom Route Place BW Complicati
Year e of ons
Birth RESIDENTS 24-HOUR OB-GYNE HISTORY
G1 - Female, NSD QCGH AGA None DATE: December 6, 2016
1992 Term HOSPITAL NO.: 622080
alive ATTENDING PHYSICIAN: Dr. Cuenca/ Alava/
G2 Male, NSD QCGH AGA None Morante/ Naguit/ Beron, Donato/ Rodriguez
1993 Term -------------------------------------------------------------------------------
alive -----
G3 Male, QCGH Home AGA None GENERAL DATA:
1995 Term deliv Name: Dela Cruz, Rema Jallane Age: 19 y/o
alive ery Civil Status: Single Birthday: 05/12/1997
G4 Male, QCGH Tond AGA None Religion: Roman Catholic
1996 Term o
alive
Address: Tondo Manila
Gene
ral CHIEF COMPLAINT: Labor pain
Hospi
tal HISTORY OF PRESENT ILLNESS:
PHYSICAL EXAMINATION: 1st trimester:
General Survey: Patient is conscious, coherent, and not The patient noted cessation of menstruation.
in cardiorespiratory distress, with the following vital Pregnancy test was done at home and it tested positive.
signs: Patient started prenatal check-up and was given
BP: 120/80mmhg CR: 82 RR: 19 T: 36.2oC Multivitamins. Ultrasound was done. Negative for any
HEENT: Anicteric sclera, pink palpebral conjunctiva, no maternal illness.
nasal and aural discharge, no tonsillopharyngeal
congestion, no cervical lymphadenopathy, no neck vein 2nd Trimester:
engorgement Patient continued her prenatal check-up and
Chest and Lungs: Symmetrical chest expansion, no continued above medications. Ultrasound was done. No
retractions, with clear breath sound, no crackles or vomiting, nausea and vaginal bleeding. Noted good fetal
wheezes movement.
Heart: Adynamic precordium, normal rate, regular
rhythm, no heaves, lifts, thrills, or presence of murmur, 3rd Trimester:
apex beat located at 5th intercostal space midclavicular Patient continued her prenatal check-up and
line continued above medications. nausea and vaginal
Breast: Symmetrical contour, no dimpling, no palpable bleeding. Negative for any maternal illness.
mass, no tenderness, no abnormal nipple discharge
Abdomen: Globular, soft, no tenderness noted upon Few hours prior to admission, the patient noted
palpation, normoactive bowel sounds vaginal bleeding accompanied by hypogastric pain.
Hence sought consult in our institution.
Extremities: grossly normal extremities, no
deformities, no cyanosis, no edema PAST MEDICAL HISTORY:
Skin: brown, warm to touch, moist, with good skin (-) HPN (-) Heart Disease (-) Previous surgery
turgor, capillary refill <2 sec (-) DM (-) PTB (-) Thyroid disease
(-) Asthma (-) Liver Disease (-) Kidney
Speculum exam: not done Disease
Internal examination: not done FAMILY HISTORY:
(-) HPN (-) Thyroid disease (-) PTB
ASSESSMENT:Gravida 4 Para 4 (4004) Pelvic Organ (-) DM (-) Heart Disease (-) Asthma
Prolapse stage IV (-) Liver Disease (-) Kidney Disease
(-) Malignancy
PLAN: For Vaginal Hysterectomy, Kelly plication, Anterior
Posterior repair PERSONAL AND SOCIAL HISTORY:
(-) Smoking
(-)Alcoholic beverage drinker
(-) Illicit Drug Use
(-) Allergy to food and drugs
MENSTRUAL HISTORY:
Menarche: 11 years old
Interval: 28-30 days
Duration: 4-5 days
Amount: 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: 17
Number of Sexual Partners: 1
Contraceptive: Oral contraceptive none
GYNECOLOGIC HISTORY:
(-) Dyspareunia (-) Post Coital Bleeding
(-) Chronic Pelvic Pain (-) Foul-smelling discharge
(-) Postcoital bleeding
SEXUAL HISTORY:
First Sexual Contact: 17 years old
Number of Sexual Partners: 3
Contraceptive: none
OBSTETRIC HISTORY:
LMP: 2015
PMP: N/A
Menoupause: 36 years old
G5P5 (5005)
Gravida Outcom Route Place BW Complica
Year e of tions
Birth
G1 - Male, Normal Rizal AGA None
1997 Term spontane provinc
alive ous ial
delivery Hospit RESIDENTS 24-HOUR OB-GYNE HISTORY
al DATE: December 6, 2016
G2 Female, Normal Rizal AGA None HOSPITAL NO.: 2016094313
2000 Term spontane provinc ATTENDING PHYSICIAN: Dr. Cuenca/ Alava/
alive ous ial Morante/ Naguit/ Beron, Donato/ Rodriguez
delivery Hospit -------------------------------------------------------------------------------
al -----
G3 Male, Normal Makati AGA None GENERAL DATA:
2001 Term spontane , Lying Name: Carmen, Stephanie Alba Age: 15 y/o
alive ous in
delivery Civil Status: Single Birthday: 08/13/2001
G4 Female, Normal Well AGA None Religion: Roman Catholic
2004 Term spontane Care Address: Tondo Manila
alive ous Family,
delivery CHIEF COMPLAINT: Labor pain
Lying
in
G5- Male, Cesarean Rizal AGA None HISTORY OF PRESENT ILLNESS:
2005 Term section provinc
alive ial 1st trimester:
Hospit The patient noted cessation of menstruation.
al Pregnancy test was done at home and it tested positive.
Patient started prenatal check-up and was given
PHYSICAL EXAMINATION: Multivitamins. Ultrasound was done. Negative for any
General Survey: Patient is conscious, coherent, and in maternal illness.
cardiorespiratory distress, with the following vital signs:
BP: 100/80mmhg CR: 99 RR: 27 T: 36.2oC 2nd Trimester:
HEENT: Anicteric sclera, pink palpebral conjunctiva, no Patient continued her prenatal check-up and
nasal and aural discharge, no tonsillopharyngeal continued above medications. Ultrasound was done. No
congestion, no cervical lymphadenopathy, no neck vein vomiting, nausea and vaginal bleeding. Noted good fetal
engorgement movement.
Chest and Lungs: Symmetrical chest expansion, no
retractions, with decreased breath sound on right lobe, 3rd Trimester:
no crackles or wheezes Patient continued her prenatal check-up and
Heart: Adynamic precordium, normal rate, regular continued above medications. nausea and vaginal
rhythm, no heaves, lifts, thrills, or presence of murmur, bleeding. Negative for any maternal illness.
apex beat located at 5th intercostal space midclavicular
line Few hours prior to admission, the patient noted
Breast: Symmetrical contour, no dimpling, no palpable vaginal bleeding accompanied by hypogastric pain.
mass, no tenderness, no abnormal nipple discharge Hence sought consult in our institution.
Abdomen: Flabby, soft, no tenderness noted upon
palpation, normoactive bowel sounds PAST MEDICAL HISTORY:
Extremities: grossly normal extremities, no (-) HPN (-) Heart Disease (-) Previous surgery
deformities, no cyanosis, no edema (-) DM (-) PTB (-) Thyroid disease
Skin: brown, warm to touch, moist, with good skin (-) Asthma (-) Liver Disease (-) Kidney
turgor, capillary refill <2 sec Disease
MENSTRUAL HISTORY:
Menarche: 12 years old
Interval: 28-30 days
Duration: 3 days
Amount: 3 pads per day, moderately soaked
Symptoms: (+) Dysmenorrhea
GYNECOLOGIC HISTORY:
(-) Dyspareunia (-) Post Coital Bleeding
(-) Chronic Pelvic Pain (-) Foul-smelling discharge
(-) Postcoital bleeding
SEXUAL HISTORY:
First Sexual Contact: 14
Number of Sexual Partners: 1
Contraceptive: Oral contraceptive none
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: Oral contraceptive none
OBSTETRIC HISTORY:
LMP: June, 2016
PMP: May 2016
Menoupause: N/A
G4P3 (3013)
Gravida Outcom Route Place BW Complicati
Year e of ons
Birth
G1 - Abortio
1978 n
G2 Male, NSD MCU AGA None
1979 Term
alive
G3 Male, QCGH Lying AGA None
1980 Term -In
alive
G4 Male, QCGH Home AGA None
1982 Term Deliv
alive ery
PHYSICAL EXAMINATION:
General Survey: Patient is conscious, coherent, and not
in cardiorespiratory distress, with the following vital
signs:
BP: 140/90mmhg CR: 79 RR: 19 T: 36.5oC
HEENT: Anicteric sclera, pink palpebral conjunctiva, no
nasal and aural discharge, no tonsillopharyngeal
congestion, no cervical lymphadenopathy, no neck vein
engorgement
Chest and Lungs: Symmetrical chest expansion, no
retractions, with clear breath sound, no crackles or
wheezes
Heart: Adynamic precordium, normal rate, regular
rhythm, no heaves, lifts, thrills, or presence of murmur,
apex beat located at 5th intercostal space midclavicular
line
Breast: Symmetrical contour, no dimpling, no palpable
mass, no tenderness, no abnormal nipple discharge
Abdomen: Globular, soft, no tenderness noted upon
palpation, normoactive bowel sounds