ROCK ELDRICK A.

GALZOTE
2019-2109425
DEPARTMENT OF OBSTETRICS AND GYNECOLOGY
PAPER CASE 1

IDENTIFYING DATA
Patient R.S. a 39 y/o G5, married, Roman Catholic, living in Tatalon, Quezon city came
in for a consult at UERMMMCI on August 12, 2021.

CHIEF COMPLAINT
Hypogastric pain of one week duration; prenatal checkup

HISTORY OF PRESENT ILLNESS

The patient sought consult due to hypogastric pain and prenatal checkup. The patient is
presumed to be pregnant due to enlarging abdomen and missed menses for 3 months but did
not take a pregnancy test.

One week PTC, the patient experienced hypogastric pain with 3/10 intensity occurring in
the afternoon. The patient did not take any medication and the pain was alleviated by rest alone.

Pertinent findings include no vaginal bleeding, and the patient already experienced some
movement inside her womb.

The patient continues to experience hypogastric pain at the day of consultation which
prompted the patient to visit the clinic and to get a prenatal checkup.

OB-GYN HISTORY
Menstrual: Menarche at 13 y/o, regular, 28-30 day interval, approximately 6 days
duration, around 4 fully soaked pads per day; with infrequent dysmenorrhea; LMP: February 19,
2021; PMP: January 17, 2021.

Obstetric: G5P3 (2113)

G1: 2005, NSD, Full term, male, traditional birth attendant “hilot”, no complications
G2: 2010, NSD, Preterm, female, lying in, no complications
G3: 2012, Ectopic pregnancy, tubal, had left salpingectomy
G4: 2019, NSD, Full term, female, delivered in a hospital (UERM), no complications
G5: Current pregnancy; AOG: 24 6/7 weeks EDD: November 26, 2021

Gynecologic: Was not elicited.

Sexual: Sexual debut at age 23, only 1 sexual partner, no history of dyspareunia, no history of
post-coital bleeding, 1-2 times a week of sexual intercourse.

Contraception: History of IUD use for 5 years, history of taking pills for 1 year - discontinued
because it was too inconvenient for the patient.

Immunization: The patient is unsure of her MMR vaccine, contracted the Varicella virus, had a
Tetanus shot 10 years ago, completed the Hepatitis B vaccine, no flu vaccine, and no HPV
vaccine.

PAST MEDICAL HISTORY

No childhood diseases, no allergies, no major illnesses, past surgery was for her ectopic
pregnancy and past hospitalizations were only for her previous pregnancies.

FAMILY HISTORY
History of hypertension of her father and her grandmother, her sister has breast cancer,
no history of congenital diseases, mental illnesses, diabetes mellitus, and preeclampsia.

PERSONAL/SOCIAL HISTORY
The patient is a non smoker, occasional drinker, no history of illicit drug use, no known
occupational hazard, and no known environmental risks.

REVIEW OF SYSTEMS
Description

General unremarkable
(-) fever, (-) fatigue, (-) weight loss, (-) body malaise

Skin unremarkable
(-) color, (-) texture, (-) itching, (-) rashes, (-)
changes in hair/nails

Eyes unremarkable
(-) visual impairment, (-) redness, (-) tearing, (-)
pain, (-) double vision, (-) discharge, (-) trauma

Ears unremarkable
(-) hearing loss, (-) otalgia, (-) discharge, (-) tinnitus

Nose, Throat, Mouth unremarkable

(-) nasal obstruction, (-) discharge, (-) abnormal
olfaction/anosmia, (-) epistaxis, (-) frequent
colds/cough, (-) dysphagia, (-) odynophagia, (-)
change in voice, (-) neck mass, (-) toothache, (-)
dental caries, (-) gum bleeding, (-) ulceration, (-)
congenital deformities
Respiratory
(-) cough, (-) difficulty of breathing, (-) wheezing unremarkable
(asthma), (-) PTB exposure, (-) hemoptysis, (-)
tachypnea (-) COVID

Cardiovascular unremarkable
(-) palpitation, (-) chest pain, (-) syncope, (-) edema,
(-) hypertension, (-) orthopnea, (-) dyspnea, (-)
tachycardia

Gastrointestinal unremarkable
(-) dysphagia, (-) nausea, (-) vomiting, (-) loss of
appetite, (-) abdominal pain, (-) melena, (-) jaundice,
(-) bleeding, (-) indigestion, (-) heartburn, (-)
hematemesis, (-) fatty food intolerance, (-) stool
frequency/character, (-) hemorrhoids, (-) abdominal
distention, (-) hernia

Urinary unremarkable
(-) pain, (-) volume, (-) retention, (-) bleeding, (-)
stream, (-) polyuria, (-) nocturia, (-) stones, (-)
infection, (-) hesitancy, (-) urgency, (-) change in
color, (-) frequency, (-) dribbling

Genito-reproductive unremarkable
(-) discharge, (-) pain, (-) libido, (-) sexual difficulties

Extremities unremarkable
(-) cyanosis, (-) clubbing, (-) edema, (-) varicosity, (-)
ulcers, (-) claudication

Hematopoietic System unremarkable

(-) excessive bleeding/bruising, (-) anemia, (-) pica

Nervous System unremarkable

(-) headache, (-) tremor, (-) fainting spells, (-)
seizures, (-) dizziness/ vertigo, (-) head trauma, (-)
sensory perversions

Musculoskeletal unremarkable
(-) joint stiffness, (-) pain, (-) swelling, (-) muscle
weakness

Endocrine System unremarkable

(-) DM, (-) heat/cold intolerance, (-) thyroid
problems, (-) neck surgery/irradiation

Psychiatric unremarkable
(-) Mood swings, (-) Behavioral Changes, (-)
Anxiety, (-) Depression
REFLECTION
The activity provided a new aspect of history taking. I was a little caught off guard
because I was used to taking patient history that focuses on a particular problem the patient
was having and focusing on the history of the present illness itself while this one focused more
on the OB-GYN history and the different aspects that it encompasses (menstrual, sexual,
gynecologic, etc.) For me, the activity provided a new challenge in terms of how to gather
information from the patient about her OB-GYN history which in and of itself is already a very
broad topic let alone trying to elicit and determine what information is relevant or not. All in all, it
was a refreshing experience and in my opinion a very good way to start the semester.