I. GENERAL DATA Name: J.D.J. Age: 48 y.o. Address: Quinabonglan, Maayon, Capiz
II. HISTORY OF PRESENT ILLNESS
Patient initially went to a private OB clinic because of amenorrhea, according to her she had undergone ultrasound and was told to be pregnant and had myoma. No official result of ultrasound was given to the patient. She went to her midwife last January 9, 2019 for pre- natal check-up. She was requested with CBC, typing, urinalysis, Hepa B and RPR. She then Referred back to a private practitioner (her OB) because of High Risk Pregnancy.
III. PAST MEDICAL HISTORY
No significant past medical history.
IV. OB/GYNE HISTORY
G8, P7 (7007) LMP: 10/15/2018 Gestational Age:
TIMING NO. and DATE PROVIDER ASSESSMENT PLAN/ACTIONS
OF VISITS TAKEN/SERVICES GIVEN 1ST Trimester 1) 1/9/19 RHM Temp- 36.3 Services Given BP- 100/60 Wt-50.2 2nd Trimester 2) 3/13/19 RHM Temp- 36.7 Request for: BP- 100/60 CBC, Typing Wt- 50.7 U/A FHB- 144 UTZ Advised consultation with OB- Gyne of Choice
3) 4/14/19 RHM Temp- 36.7 Ferrous Sulfate with
BP- 100/70 Folic acid given Wt- 50.7 4) 5/8/19 RHM Temp- 36.8 Ferrous Sulfate with BP- 100/70 folic acid given Wt- 51.4 5) 6/10/19 RHM Temp- 36.8 Ferrous Sulfate with BP- 100/70 folic acid given Wt- 51.7