General Data

Ms. FMD is an 18 year old, single Grade 11 student, Aglipayan resident of Piddig, Ilocos Norte.
Informant: Patient 90%
Referral: RHU

Chief Compliant
For prenatal check up

History of Present illness

The condition of the patient started 3 hours prior to admission as the patient was referred from their RHU for
prenatal check up at the OB-GYN OPD for her planned labor and delivery at MMMH & MC. From apparent well
state the patient felt an increasing number of contraction ranging from 2-3 contractions/ hour to 4-5 contractions
during subsequent hours with longer duration of contraction and shorter interval in between. The patient also
experienced intermittednt mild cramping hypogastric pain radiating to her sides, bilaterally. No vaginal bleeding, no
rapture of membranes noted. Upon pelvic exam the cervix was dilated 2 cm hence advised for admission.

Past medical history

The patient had experienced measles, varicella and tonsillitis during her elementary years. She also claimed to have
completed her primary childhood immunization.

Patient denied undergoing any surgery. Patient has history of fall when she was in grade 6 in which she sustained 5
cm laceration in her anterior left scalp which was closed by suture in their RHU.

She had her thelarche at 9 years old, pubarche at 11 years old and her menarche at 12 years old. She have an
irregular menstrual flow that usually skips 1 month. The typical duration of her flow is 9 days. She has a heavy flow.
She also experience dysmenorrhea.

She had her coitrache at 16 years old. Uses condom and withdrawal method infrequently. No history of OCP use.
Has 1 sexual partner. Patient denied any abnormal discomfort and bleeding. During sexual activity

LMP: March 17, 2017

PMP: 2nd week for February, 2017

EDC: December 22, 2017

Via sonography: December 24, 2017

AOG: 35 4/7 weeks

OB score: G1P0

Pregnancy was unplanned. Discovered she was pregnant in June 2017 via pregnancy test. She undergoes regular
prenatal check up at their RHU and already had 4 visits. She had her 1 st prenatal check up around the last week of
June wherein she was diagnosed with Anemia and was given Ferrous Sulfate. She noted blackening of stools and
constipation but continued to take medication. She was also diagnosed with UTI and was given cefuroxime bid x 1
week and completed the course of her antibiotic treatment. She had her 2 nd prenatal check up in July where she still
experience symptoms of UTI hence was advised to take amoxicillin but the patient didn’t take it. She has her 3rd
prenatal check up in August and had undergone ultrasonography. She had her 4 th prenatal check up in October 23
and was assessed to have an elevated BP but patient denied experiencing any symptoms of dizziness, headache, easy
fatigability, blurring of vision, leg swelling, decrease frequency of urination, easy bruising or bleeding, and changes
in fetal activity. She was advised a low salt and low fat diet. She was also advised seek consult at MMMH & MC
however she did not follow because according to the patient, she did not feel any symptoms.

Patient was given 1 dose of Tetanus toxoid during her prenatal check up last October 23.

Patient denied having dental check-up during pernatal care. She had her last dental check-up in January 2017 due to
toothache.