Far Eastern University

Dr. Nicanor Reyes Medical Foundation

School of Medicine
Department of Obstetrics and Gynecology

DATE: September 19, 2022 INFORMANT: Patient

History taken by: JI RELIABILITY: 90%

GENERAL DATA:
______________, __years old, presently residing at____, admitted for the __ time at FEU-
NRMF Medical Center on September 19, 2022.

PATIENT’S PROFILE

Date of Birth: Attitude: Cooperative

Birthplace: Habits: Non-smoker and non-alcoholic
Religion: beverage drinker
Status: Availability of relatives: Nearby
Occupation:

CHIEF COMPLAINT:

HISTORY OF PRESENT ILLNESS:

LMP: ___
PMP: ___
EUTZ: (date)

The history of present illness started ____ prior to consult when the patient felt ___

If pain, ask PQRST

If bleeding, include bleeding pattern

PAST MEDICAL HISTORY:

● The patient had history of childhood diseases such as measles, mumps and
chickenpox.
● She has completed her childhood vaccinations with unrecalled dates.
● She denies any history of major illnesses, trauma, accidents, previous
hospitalizations, or major operations.
● She has no history of Diabetes Mellitus, heart, liver, kidney, lung or thyroid
diseases.
● She has no allergies to food and drugs.
 ● Covid-19 vaccination

FAMILY HISTORY:
● The patient's father is __ years old, apparently well.
● Her mother is _ years old, apparently well.
● Patient has siblings, all are apparently healthy.
● Patient denies other heredofamilial diseases such as cancer, liver, kidney,
lung, or thyroid diseases.

PERSONAL AND SOCIAL HISTORY:

● The patient is the __ among _ siblings with _ brothers.
● She is a ______ graduate with a degree of ____
● Presently working at ____
● Been married to ______ for ____ years
● She is a nonsmoker and a non-alcoholic beverage drinker.
● She has no food preference
● and denies any history of drug intake.

REPRODUCTIVE HISTORY

A. GYNECOLOGIC HISTORY
● The patient had her menarche at ____ (age).
● She has been ( ) regular/( ) irregularly menstruating since
○ _______ (age) years old
○ with an interval of ___________ (interval) days,
○ lasting for ______ (duration) days,
○ __________(amount) in flow, with
■ Notes:
■ Mild flow: Blood is in the center of the pads
■ Moderate: In between mild and heavy
■ Heavy: Blood reaches the pad borders
○ ________ (number) pads consumed per day,
○ ( )associated / ( )not associated with dysmenorrhea.
● (Use this line if px is abnormal after regular menses[?])
○ Subsequent menses were ( ) regular/( ) irregularly, lasts for ___,
with an interval of ____ (interval) days, lasting for ______
(duration) days, _____(amount) in flow, with _____ (number)
pads consumed per day, ( )associated / ( )not associated with
dysmenorrhea.

● She denies any history of ()dyspareunia, ()post-coital bleeding, ()

leucorrhea, and ()exposure to sexually transmitted disease.
● Pap smear was done last _______ and revealed ()normal/()abnormal
result ______.
● Reason for the Pap smear was __________.

B. OBSTETRICAL HISTORY
The patient is a ____.
● The patient is ()primigravid/()multigravid, with an OB score of G__P__
(T_P_A_L_).
 ● The first pregnancy was delivered on _____(date)
● to a ()term/()preterm, ()living/()stillbirth, ()boy/()girl,
● with a birthweight of _________grams,
● delivered via ()NSD/()forceps assisted delivery/ ()transverse LSCS,
● due to ____________ (indications) at ()home/()hospital/()lying-in clinic
● assisted by a ()midwife/()traditional birth attendant/()obstetrician.
● No fetomaternal complications were noted.
● He/She is now _______y/o and apparently healthy.
● The second pregnancy was [Copy paste green text if more than one child]
● NOTE: If with abortion, the ______(#) pregnancy was terminated by
()spontaneous/()induced abortion on _______(date) at ______(AOG).
Dilatation and curettage was done at _____(place) on _______ (date).

C. METHOD OF CONTRACEPTION
● The method of contraception use is ( ) coitus interruptus/( ) oral
contraceptive pills/( ) barrier method/( ) IUD from ____(Month, Year) to
____(Month, Year).
● OR (delete what is not needed)
● The patient denies use of contraception.

D. SEXUAL HISTORY
● The patient had her coitarche at _____ (age) with ________ sexual
partners. Her partner had _____ sexual partners. She is currently in a ( )
monogamous, ( ) hetero, ( ) homo relationship.
● OR (delete what is not needed)
● Patient had no sexual partners

REVIEW OF SYSTEMS
Constitutional Symptoms: (-) weight loss; (-) weakness; (-) fatigue; (-) chills; (-) loss of
appetite
Skin: (-) itchiness; (-) excessive dryness/sweating; (-) change in color (-) cyanosis, (-) pallor,
jaundice, erythema
Head: (-) headache; (-) dizziness/vertigo
Eyes: (-) pain; (-) blurring of vision; (-) double vision; (-) lacrimation; (-) photophobia; (-) use of
eyeglasses
Ears: (-) earache; (-) deafness; (-) tinnitus; (-) ear discharge
Nose and Sinuses: (-) changes in smell; (-) nose bleeding; (-) nasal obstruction; (-) nasal
discharge; (-) pain around paranasal sinus
Mouth and Throat: (-) toothache; (-) gum bleeding; (-) disturbance in taste; (-) sore throat; (-)
hoarseness
Neck: (-) pain; (-) limitations of movement; (-) presence of mass
Breast: (-) pain; (-) lumps; (-) whitish nipple discharge
Respiratory System: (-) dyspnea (DOB/SOB); (-) chest pain; (-) cough; (-) sputum production;
(-) hemoptysis; (-) wheezing; (-) Hx of asthma
Cardiovascular System: (-) substernal pain; (-) palpitations ; (-) dyspnea (DOB/SOB);
(-) orthopnea; (-) paroxysmal nocturnal dyspnea; (-) easy fatigability
Gastrointestinal: (-) nausea; (-) vomiting; (-) dysphagia; (-) diarrhea; (-) constipation; (-)
hematemesis; (-) melena; (-) hematochezia; (-) regurgitation
Genitourinary Tract: (-) dysuria; (-) urinary frequency; (-) urgency; (-) hesitancy; (-) polyuria; (-)
hematuria; (-) incontinence; (-) genital pruritus; (-) urethral discharge
Extremities: (-) edema; (-) swelling of joints; (-) stiffness; (-) Right hand numbness; (-)
intermittent claudication; (-) limitation of movement on right hand in the morning
Nervous System: (-) headache; (-) vertigo; (-) syncope; (-) loss of consciousness; (-)
weakness; (-) paralysis; (-) numbness; (-) paresthesia; (-) speech disorder; (-) loss of memory;
(-) confusion
Hematopoietic System: (-) bleeding tendencies; (-) easy bruising; (-) Hx of transfusion
reactions
Endocrine System: (-) heat/cold intolerance; (-) excessive weight gain/loss; (-) polyuria; (-)
polydipsia

PHYSICAL EXAMINATION:
General Survey: The patient is conscious, coherent, not in cardiopulmonary distress with the
following vital signs:
BP: __ mmHg HR: __ bpm RR: __ cpm Temp: 36._ O2sat: 9_%
Height: __ cm Weight: __ kg BMI: __ kg/m2 (pag pregnant no need)

Normal PE is as follows
HEENT: Anicteric sclera, pink palpebral conjunctivae, no nasal discharge, no tonsillopharyngeal
congestion
Neck: No neck vein engorgement, no cervical lymphadenopathy, No masses
Chest: Symmetrical chest expansion, no retractions, no lagging
Lungs: Vesicular breath sounds, no crackles, no wheezes
Heart: adynamic precordium, normal rate, regular rhythm, no murmur
Breast: No pain, no lumps, no dimpling, no tenderness, no nipple discharge
Abdomen: Soft, Symmetrical, globularly distended (depende to kung buntis or hindi), no fluid
wave, no shifting dullness, no palpable mass, non-tender, no pulsations appreciated, FHT,
Leopolds, engaged or not, breech or cephalic presentation included pag buntis
Speculum examination: Not done
Internal Examination: Not done
Extremities: No gross deformities, full and equal pulses, no bipedal edema, no cyanosis

ASSESSMENT: [Initial/ admitting diagnosis]

PLAN: (Definitive Plan for example for Normal Spontaneous Deliver/CS Delivery)
JI