CHIEF COMPLAINT: Vaginal bleeding

Present Illness
The patient first noticed vaginal bleeding this morning when she woke up at
6:25 am to use the restroom. She noticed bleeding in her clothing and blood
clots in the toilet bowl. She reports bleeding 1 cup (~250cc) total this
morning. In addition, she has a positive h/o placenta previa with her current
pregnancy determined by ultrasound. She denies any similar episodes in the
past with either pregnancy, as well as having pain, cramps, nausea, fever,
chills or recent trauma.

PAST MEDICAL HISTORY: 

OB PMH:
- Menarches: 15 years old
- Menses: Regular 28 day cycles with 4 day duration menses; heavy flow first
two
days and becomes gradually lighter toward end of menses
- Contraception hx: Denies use of barrier or hormonal methods.
2012: C-section secondary to non-reassuring fetal heart tracings, boy, weight:
7 lbs. Given for adoption.

FAMILY HISTORY : Maternal grandmother had coronary artery disease. She

has no family history of diabetes or cancer. She has no known family history
of depression or anxiety.

SOCIAL HISTORY : Patient is currently unemployed. She lives in the Seattle

area with her roommate. She is recently engaged, and states that she feels
safe at home and with her fiancé. She describes him as loving and attentive
and on questioning, denies that he has been emotionally, sexually, or
physically abusive. She denies alcohol, tobacco, or drug use.
 13 Areas of Assessment

1. Psychosocial and Psychological Status

Patient X is a 35 year-old female and is engaged. She lives with her parents
and presently residing at #94 Happy Homes Baguio City. The patient and her
family is Roman Catholic and have no practices or beliefs which might affect
to providing health care. Watching the television, eating and singing is her
way in spending her leisure time. She has positive outlook with her life

2. Mental and Emotional Status

The patient is conscious, alert and coherent. She is very responsive in verbal
stimuli, noise,light, touch and pain stimuli. She is oriented to current time,
date and place. She acts according to her age. She has good perception about
her health. She is very cooperative and prevents somethings to further cause
damage to her health. The patient responded not that interested on
thequestions I asked. No social concerns or fears were noted and no
medicines or substances were taken to alter emotional response. She
verbalized that she is not stressed but very bored.

3. Environmental Status
There are no sensory deficits and she is oriented that she is in the
hospital. Patient is knowledgeable about her conditions. There is steady pattern
of activity, light noise and color in hes environment and it does not distract her.
She is comfortable during sleep. The food and water or side table is placed at the
left side of the patient it is accessible for her needs. Patient is in the ob ward
together with her mother.
4. Sensor Status
a. Visual Status
There is no known visual deficit like color blindness. She can also
distinguish voice even from a distance, loud or soft. The patient is able to
discriminate an odor from the other. The patientis able to discriminate
sweet, sour, salty and bitter tastes from each other. With regards to
the patient’s tactile status, she was able to determine that the patient is
able to discriminate sharp anddull, light and firm touch, able to perceive
heat, cold, pain in proportion to stimulus, able todifferentiate common
objects by touch by doing necessary procedure. Patient has an intact
bodyimage and there is no aberrant sensation

b. Auditory
She can also distinguish voice even from a distance, loud or soft.
No corrective auditory deficits. And no auditory device noted being used by
the patient.
c. Olfactory Status
The patient is able to discriminate an odor from the other
d. Gustatory Status
 The patient is able to discriminate an odor from the other. The
patient is able to discriminate sweet, sour, salty and bitter tastes from
each other
 e. Tactile Status
With regards to the patient’s tactile status, she was able to determine that
the patient is able to discriminate sharp and dull, light and firm touch, able
to perceive heat, cold, pain in proportion to stimulus, able to differentiate
common objects by touch by doing necessary procedure. Patient has an
intact body and there is no aberrant sensation.

5. Motor Status
Motor strength is assessed. There is no problem with her movements The
patient is able to move and can move all her joints normally. No prosthetic
device was noted present with the patient and all her extremities are intact.

6. Thermoregulatory Status

Date Time Temperature

7am 36.5 °C
April 05, 2019 10am 36.5 °C
2pm 36.6 °C
7am 36.5 °C
April 06, 2019 10am 36.7 °C
2pm 36.5 °C
7am 36.5 °C
April 07, 2019 10am 36.6 °C
2pm 36.6 °C

7. Respiratory Status

Date Time RR SPO2

7am 16 cpm 97 %
April 05, 2019 10am 20 cpm 95 %
2pm 19 cpm 98 %
7am 20 cpm 95 %
April 06, 2019 10am 20 cpm 96 %
2pm 18 cpm 95 %
7am 19 cpm 96 %
April 07, 2019 10am 17 cpm 95 %
2pm 17 cpm 97 %

8. Circulatory Status

Date Time CR Capillary

April 05, 2019 7am 98 bpm
10am 94 bpm 1-2 seconds
2pm 95 bpm
 April 06, 2019 7am 89 bpm
10am 78 bpm 1-2 seconds
2pm 90 bpm
7am 87 bpm
April 07, 2019 10am 97 bpm 1-2 seconds
2pm 90 bpm

9. Nutritional Status
The patient food is being served in the hospital . The patient appetite is good.
There is no change in the appetite in eating during the hospitalization and health
deviation. Teeth are complete without dental carries. The skin is smooth and with
brownish color. The nails were fine and well trimmed. There is no culture or
religious dietary restriction reported by the patient. The patient is able to swallow
in her food and medications as well.

10. Elimination Status

Patient voided 3 times a day. Yellowish color. Patient defecates once a day
with a brownish stool color.

11. Sleep, Rest and Comfort Status

The patient sleeps experience sleep disturbance, as reported.

12. Fluids and Electrolytes Status

Patient is able to consume 350 cc of water. She has dry lips. She has a
good skin turgor; skin and hair are slightly dry and has pinkish nail beds. No signs
of dehydration noted as well as edema formation.

13. Integumentary Status

Patient is well groomed. Dry skin and fair skin color without pigmentations,
no pallor, lesions, jaundice or cyanosis. She has good skin turgor. Her nail
base is soft when palpated, with capillary refill of 1-2 seconds. Her hair are
dry, evenly distributed, no parasite infestations, and well-trimmed.