Mercadejas, Astherielle Seraphine Zaldua DOB: 03/09/1997

Penaflorida Clinic
Bollos Street
Mercadejas, Astherielle Seraphine Zaldua Bayawan City 6221
Philippines
09260358910

Patient Data:

Who Title: Mrs.

Name: Astherielle Seraphine Zaldua Mercadejas
External ID: 38 DOB: 1997-03-09
Sex: Female Marital Status: Married
Gender Identity: Identifies as Female Sexual Orientation: Straight or heterosexual
Contact Address: COSTA LEONA City: KALIBO, AKLAN
Postal Code: 5600 Country: Philippines
Mother`s Name: Dorothea Figueroa Zaldua Emergency Contact: 09167457677
Trusted Email: zamielmercadejas@gmail.com
Choices Care Team Status: Active
Employer Occupation: Architect Employer Address: Samaniego Industries
City: Manila Postal Code: 1007
Industry: Engineering Firm
Stats Language: English
Race: Filipino Religion: Roman Catholic Church
Guardian Name: Zarrick Amiel Almadovar Mercadejas Relationship: Life partner
Sex: Male City: Kalibo, Aklan
Postal Code: 5600 Country: Philippines
Work Phone: 09654825584

History Data:

[ ] Varicose Veins
[ ] Hypertension
[ ] Diabetes
[ ] Sickle Cell
[ ] Fibroids
[ ] PID (Pelvic Inflammatory Disease)
[ ] Severe Migraine
[ ] Heart Disease
[ ] Thrombosis/Stroke
[ ] Hepatitis
General Risk Factors:
[ ] Gall Bladder Condition
[ ] Breast Disease
[ ] Depression
[ x ] Allergies
[ ] Infertility
[ x ] Asthma
[ ] Epilepsy
[ ] Contact Lenses
[ ] Contraceptive Complication (specify)
[ ] Other (specify)

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Zaldua
 Mercadejas, Astherielle Seraphine Zaldua DOB: 03/09/1997
Breast Exam Normal 1/9/2023
Cardiac Echo Normal 2/23/2021
ECG Normal 8/9/2022
Gynecological Exam Normal 2/14/2023
Exams/Tests: Mammogram Normal 3/14/2023
Physical Exam Normal 4/10/2023
Flu Vaccination Normal 1/31/2021
Pneumonia Vaccination Normal 3/31/2021
LDL Normal 4/8/2023
Family History Father: Teodorico Zaldua Mother: Dorothea Zaldua
Spouse: Zarrick Amiel Mercadejas
Relatives Heart Problems: Teodorico Zaldua
Lifestyle Tobacco: Never smoker ( SNOMED-CT:266919005 ) Status: Never

Coffee: Status: Never

Alcohol: Status: N/A

Recreational Drugs: Status: Never

Counseling: Status: Never

Exercise Patterns: Status: Current

Hazardous Activities: Status: Never

Sleep Patterns: 8-10 hours q day

Insurance Data:

Primary Insurance Data:

Provider:
Koshi Insurance
Secondary Insurance Data:
Tertiary Insurance Data:

Billing Information:

Patient Immunization:

2023-04-10 16:01:00 - varicella

Recurrent Appointments:

None

Issues

Allergies:

penicillin:
Mercadejas, Astherielle Seraphine 2/7 2023-04-10 16:36
Zaldua
 Mercadejas, Astherielle Seraphine Zaldua DOB: 03/09/1997
Medical Problems:

asthma:
[Diagnosis]
ICD10:J45.909: Unspecified asthma, uncomplicated

Medications:

Fluticasone:
[Diagnosis]
ICD10:J45.909: Unspecified asthma, uncomplicated

New Patient Encounter

(2023-04-10) Provider: admin admin

Facility: Koshi Clinic
Category: Office Visit
Reason: Prenatal Visit
Provider: admin, admin
Referring Provider: ,
POS Code: 00

Review of Systems Checks

(2023-04-10)
Night Sweats: yes Fatigued: yes Exposure To Foreign Countries: yes Headaches: yes

SOAP

(2023-04-10)
Subjective: " Sakit akong ulo"
"Morning Sickness"
" I have fatigue"
"Daghan kaayo kong cravings di ko kasabot"
Objective: Vital Signs
T:36.7 °C
BP: 110/80 mmHg
RR: 16 bpm
HR: 90 bpm
SaO2:99%
Assessment: The patient appears to be active, alert, oriented to time, place, person, and situation. Her wavy hair is unruly, no
foul odor was noted. Recent and remote memory intact. Good insight and cognitive function. No aphasia, dysarthria, or
hoarseness. The patient has brown skin, warm, dry, with good skin turgor. No abnormal pigmentation, bleeding, rash, and
other lesions noted. Gait and station are normal.Good skin turgor, time for the skin to return to its normal position is less than 2
seconds.Head is normocephalic. Conjuctiva ,Equally pink in both eyes, no paleness noted, PERLA. Breast has No dimpling,
masses, tenderness noted.
Plan: Assure patient. Build Rapport.
Observe for physical exam, weight checks, and provide a urine sample. Obtain blood tests and imaging tests, such as
ultrasound.
Health Educate on Prenatal Care

Vitals

(2023-04-10)
Blood Pressure: 110/80 Height: 70 in (177.8 cm) Weight: 130 lb (58.97 kg) Temperature: 98.42 F (36.90 C)
Temp Method: Axillary Pulse: 90 per min Respiration: 16 per min BMI: 19 kg/m^2
BMI Status: Normal Waist Circ: 27 in (68.6 cm) Oxygen Saturation: 99 %

Document 'DS.PNG-557'

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 Mercadejas, Astherielle Seraphine Zaldua DOB: 03/09/1997

Document 'VITAL SIGNS.PNG-556'

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 Mercadejas, Astherielle Seraphine Zaldua DOB: 03/09/1997

Document 'ZALDUA-BG.PNG-540'

Document 'ZALDUA-BG.PNG-541'

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 Mercadejas, Astherielle Seraphine Zaldua DOB: 03/09/1997

Document 'ZALDUA- PH.PNG-543'

Document 'PAST HEALTH HISTORY.PNG-546'

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Zaldua