OSPITAL NG MAYNILA MEDICAL CENTER DEPARTMENT OF OBSTETRICS & GYNECOLOGY

Interdepartmental Referral Form Name: Age/Sex: Date of Admission: Admitting Diagnosis: Physicians-In-Charge: Drs. Guinto/ Dela Cruz/ Trinidad/ Amado/ Mending Clerks-in-Charge: JI Federigan/ Francisco/ Garibay/ Guanlao/ Hilario/ Lozada Referring to: Referring Physician: ______________________________ Receiving Physician: ______________________

Department of

Reason for referral:

CLINICAL ABSTRACT This is a case of a ___ year old female who came in due to HISTORY OF PRESENT ILLNESS: OB HISTORY: Year G1

Sex

Outcome

Method

Place

FMC

PAST MEDICAL HISTORY: (-) Hypertension HBP: UBP: (-) CVD (-) DM (-) BA (-) Goiter (-) allergy to food or drugs (-)previous hospitalization/surgery FAMILY HISTORY (-) HPN (-) CVD

(-) DM

(-) BA

PERSONAL AND SOCIAL HISTORY (-) Smoker (-) Alcoholic beverage drinker MENSTRUAL HISTORY M years old I regular D days A pads/day S (-) dysmenorrhea SEXUAL HISTORY Coitarche: years old No. of sexual partners: (-) OCP use (-) Dyspareunia (-) PCB

REVIEW OF SYSTEMS: General: (-) weight loss, (-) weight gain HEENT: (-) headache, (-) blurring of vision, (-)tinnitus Respiratory: (-) cough, (-) colds, (-) DOB Cardiovascular: (-) palpitations, (-) PND, (-) orthopnea Abdominal: (-) abdominal pain, (-) change in bowel movement, (-) nausea, (-) vomiting, (-) melena GUT: (-) dysuria, (-) hematuria, (-) frequency, (-) incontinence Endocrinologic: (-) polydipsia, (-) polyphagia, (-) polyuria Hematilogic: (-) easy bruisability, (-) prolonged bleeding PHYSICAL EXAMINATION General: conscious, coherent, NICRD BP: PR: RR: T: HEENT: Anicteric sclerae, pink palpebral conjunctiva, no nasoaural discharge, no tonsillopharyngeal congestion, no cervical lympadenopathy CHEST/LUNGS: Symmetrical chest expansion, no retractions, clear breath sounds HEART: Adynamic precordium, PMI 5th ICS left parasternal line; normal rate and rhythm, no murmurs ABDOMEN: flabby, soft normoactive bowel sounds, nontender EXTREMITIES: Grossly normal, full and equal pulses, no edema, no cyanosis

Summary of Laboratories

CBC with PC (date: / /12) WBC Hgb Neutrophils Hct Lymphocytes MCV Monocytes MCH Eosinophils MCHC Basophils Platelets

Urinalysis (date: / /12) Color Transparency Epithelial Cells Mucus Threads

Amorphous urates Pus cells RBC Bacteria