Patient’s Profile

i. Biographic Data
Name : Marimar
Age : 30 y/o
Gender : Female
Birthday : December 5, 1990
Civil Status : Married
Address :Davao City
Place of Birth :Tondo, Manila
Civil Status : Separated
Religion : N/A
Nationality : Filipino
Educational Attainment : High School Graduate
Occupation : Call center agent at BPO company
Family Income : Income from her work and her
present live in partner which works
also in BPO company.
Socioeconomic status :Middle socioeconomic status

ii. Clinical Data

Chief Complaint : Continuous regular contractions
Date of Admission : February 22, 2021
Time of Admission : 8:21 AM
Manner of Admission : Ambulatory
Hospital :Davao Doctors Hospital
Ward :HRU
Room and Bed No. :HR 1
Attending Physician :Dr. Ledesma
Case Type :N/A
Tentative Diagnosis :
Final Diagnosis :Human Immunodeficiency virus
 Vital Signs upon admission:

VS upon Admission Results

Temperature 38.2°C
Pulse Rate 96 BPM
Respiratory Rate 25 CPM
Blood Pressure 120/80 mmHg

iii. Past Health History

Patient Marimar was born on December 12, 1990 in Tondo,Manila. As

an individual she reportedly known as asthmatic since she was a child. To
relieve her discomfort, she would take Salbutamol tablets every time she had
an acute attack. She got hospitalized at 10 years old because of difficulty of
breathing due to her asthma.She was known as a drug user of marijuana and
shabu since she was in highschool and has been engaging in promiscuous
sexual activity. Aside from being a drug user she is also a smoker consuming
at least 1-2 sticks a day.

In 2015, patient Marimar submitted herselt for HIV testing and was
diagnosed positive. She often skips eating her meal on time because of the
nature of her work as agent of BPO company. She is very fond of eating fast
foods like burgers,pizza and others especially those which are highly spiced
with garlic. She also does not like eating vegetables. Regarding her
obstetrical data, she had her menarche at the age of 12. Her menstruation is
regular which lasts for 4-5days, in moderate to heavy flow.

She usually changes her pads 5 to 7 times a day and is soaked in the
first 3 days and moderate to light flow in the succeeding days. Patient
disclosed that her first and 2nd child were both born via Cesarean section
(CS) . She stated that during her first pregnancy the doctor told her that the
child needed immediate birth since the baby’s heart was weak. In her 2nd
pregnancy her labor took time and the doctor insisted that cesarean may be
done immediately because the baby is already defecating inside her womb.
Both cesareans done on her were successful. Her immunization record shows
that she had taken her BCG,DPT,OPV, Measles and Tetanus Toxoid x 4
doses during her 2 pregnancies.

iv. Present Health History

Patient Marimar, is a 30-year-old female, in her 34th week of pregnancy

who was transferred to the hospital after coming from a prenatal clinic and
reported to be experiencing continuous regular contractions for almost 2 days.
This is her third pregnancy. The labor and delivery team was planning to
admit her to observe and monitor her baby through a fetal Non-Stress Test
and to exclude complications associated with preterm labor. The patient
previously agreed to a scheduled repeat C-section since she already had two
prior ones. Upon admission the patient looked pale, sluggish when talking and
was shivering. She also had fever, temperature taken registered 38.2*C.

She reported having diarrhea for 3 days already, she weighs 52 kgs
the patient seldom eats green-leafy vegetables yet like to consume fastfoods
like burgers, pizza. Her vital signs were checked BP of 120/80mmhg,
respiratory rate of 25bpm and pulse rate of 96bpm. She was observed to be
coughing a few times during the interview. She also reported of back pain
especially during her uterine contractions and lower extremities. She also
reported once in while that she experiences difficulty of breathing, especially
when she is lying flat on bed at night. Lower extremities has presence of +2
edema.

The patient is under the service of Dr. Ledesma. She had herself
tested again for HIV during this present pregnancy at 20 weeks and was
immediately started on co-formulated TDF/FTC (brand name Truvada®) and
Raltegravir (Isentress®) on the day of diagnosis per current
recommendation.Her most recent HIV viral load was 1,200 copies/mL last
month, up from the previous 840 copies/mL a month prior. The patient
reported poor compliance to ART regimen and usually forgets to take her
evening Raltegravir dose . Regarding her gynecological data patient reported
that in the past year visiting her OB, she was diagnosed as having fungal
infection. She was prescribed a medication for her vaginal itchiness but had
forgotten its name. Up to now, she’s still experiencing itchiness and
oftentimes she’ll find a cream cheese like on her panty.

v. Family Health History

A genogram is a pictorial display of a person's family relationships and

medical history. It goes beyond a traditional family tree by allowing the user to
visualize hereditary patterns and psychological factors that punctuate
relationships. It is used to recognize repetitive patterns of behavior as well as
hereditary inclinations. For patient Marimar ,maternal side and paternal are
both to be hypertensive and non-diabetic.

Genogram: