PHINMA- St.

Jude College- Manila

SY: 2023-2024
BSN 2-7

Patient profile

Patient N.M. is a 25 year old female residing in Quezon City for 20 years. She was born on January 15, 1994 in Lanao del
Sur. She identifies herself as a Muslim. She finished college with a degree in Business administration in University of
Manila. After graduating, she then works as an accounting in Baitalig tradings for 4 years. Her working hours for the
weekdays is from 8:30am to 5pm and for Saturdays is from 8:30am to 3pm.

She is living with her live-in partner for 10 years in a 1-storey cemented bungalow with 3 bedrooms and 1 bathroom.
They are 13 in their household with both of her parents, her partner, her 4 siblings, and sister-in-law and 4 nieces and
nephews from her brother. Despite their number in a single household, she claims that it is not crowded. Their water
and electric supply comes from Maynilad and Meralco respectively. Their garbage collection is done every day. Their
neighborhood is generally clean and not congested. Their source of income comes from both from her husband and
herself which she claimed to be adequate for their day-to-day lives.

She usually sleeps 8 to 10 hours, without difficulty falling to sleep. Her usual diet consists mostly of fruits and vegetables,
and rarely pork and beef. She has no known allergies. She drinks 1 cup of coffee every morning and drinks alcoholic
beverages occasionally but stops when she knew that she was pregnant. She denies smoking. She denies illicit drug use.

Source: patient herself Reliability: 100%

Chief Complaint: for 2nd pre-natal check-up

History of Present Illness:

no known co-morbidity.

Patient N.M. G1P0, 18wks AOG, went to the OPD for her 2 nd prenatal check-up. She got her first pre-natal check-up at
UERM OPD, 7 days PTC where urinalysis, blood typing and CBC were done. Lab results unrecalled but was told that
everything was normal and there are no problems with her and the baby. She does not feel any nausea nor vomiting. She
is currently taking FeSo4 daily where she experienced having black tarry stool and also taking Obimin multivitamin. Her
expected date of delivery is on January 16, 2020.

Menstrual history
Menarche: 12years old
Duration: 4 days
Amount (# of pads): 2 fully soaked pads
Regularity: regular
Interval: 26 days
Problems: dysmenorrhea

Obstetrics history: G1P0 (0-0-0-0)

Gynecological history
Masses: none
Discharges: none
UTI: none
Warts: none
PHINMA- St. Jude College- Manila
SY: 2023-2024
BSN 2-7
STD: none
Ovarian cysts: none
Others:

Sexual history
Coitarche: 22 years old
# of partners: 1
Interval of sex /week: once a month
Satisfaction: yes
Problems with intercourse: none
Contraceptive use: none

Past health history

1. Childhood diseases: none
2. Allergies: (+) tulingan fish, itchy skin rashed appear, treated with Bilastine and was relieved.
3. Surgeries: none
4. Immunizations: none
5. Hospitalizations: none
6. Major illnesses:
2010- UTI, not hospitalized, treated with prescribed unrecalled antibiotics. Eventually resolved. No
complications.
7. Accidents: none

Family history