GENERAL DATA J.R is a 35-year-old Filipino, gravid female, Roman Catholic, married, born on December 05, 1985, presently residing in Capitol Cebu city, Cebu, who came in for the first time in Gullas Medical Center due to Easy fatigability and body malaise DATE OF ASSESSMENT • SEPTEMBER 9, 2021 PATIENT INFORMANT • PATIENT PATIENT RELIABILITY 80% Easy Fatigability and Body malaise CHIEF COMPLAINT HISTORY OF PRESENT ILLNESS Two months prior to consult, patient experienced easy fatigability with accompanying body malaise. She noted that on her previous pregnancies she has never easily tired like this. No medications were taken. No consultation done. Condition tolerated On the day of PTA, patient noted being easily tired even with just a little exertion or having a 50 meter walk which is relieved with rest. She also experienced body malaise which prompts her to seek consult. There is no shortness of breath, no dizziness, no vomiting. OBSTETRICS HISTORY • • • • LMP: Feb 11, 2021 AOG: 30 weeks 2 days EDD: Nov 18, 2021 OB SCORE: G3P2(2002) GYNECOLOGICAL/ HISTORY LMP is February 11, 2021. Menarche at 13 years old, regular , usually last for 3 to 4 days with a 28-30 day menstrual cycle. Patient’s usually used 1 to 5 pads of sanitary napkin per day. She claims to have not experienced dysmenorrhea, cramps and no history of vaginal bleeding, pain and abnormal discharges. Coitarche at 23 and claims that she only have 1 sexual partner which is her husband. No use of any contraceptive methods/devices and pap smear performed 2 years ago, at age 13, year 2019, exact date unrecalled with results unremarkable. No concerns of HIV infections. MEDICAL/SURGICAL HISTORY Patient is non-hypertensive and non-asthmatic. She claims to be fully vaccinated in her childhood. She experienced common cold, cough and fever in her childhood which are relieved by over-the-counter medications. No history of previous hospitalization. No Psychiatric history. No known food and drug allergies HISTORY OF FIRST TRIMESTER • Patient reported fetal movements on her 4th months AOG. She noted 2-3x daily kicking or movements of the fetus, specially a lot after eating meals. She does not have morning sickness, no signs of hypertension, vaginal pain, bleeding, discharges, swelling of extremities, fever, and no bowel irregularities. HISTORY OF SECOND TRIMESTER • During her 20th week of pregnancy, patient’s first prenatal visit., given tetanus toxoid injection. Patient had her first prenatal check-up at 20th weeks AOG at Gullas medical center with regular follow-up in same hospital thereafter. She was given tetanus toxoid (2 doses), 1st dose at 20th week of gestation and 2nd dose at 24th week of gestation. Patient started regular checking her BP at 6 mos. of her current pregnancy, BP are all within normal. Prescribed with Iron Supplement (Hemarate) OD, Calcium (Calciumade) OD and Multivitamins (Obimin Plus) OD all taken with poor compliance. Patient discontinued taking her iron supplements due to unpleasant taste. Patient reported quickening felt and a strong movement of the fetus was noted. She also claims to have not experienced signs of hypertension, vaginal pain, bleeding, discharges, swelling of extremities, fever, and no bowel irregularities. HISTORY OF THIRD TRIMESTER • Routine prenatal check-up visits done. Before her current pregnancy, the patient weighs 50 kg. Current is 56 kg, and height is 146 cm. She claims that her diet is around 2100 kcal per day. Her recommended daily caloric intake is 2400 kcal which net her a caloric deficit of about 300 kcal. Computed BMI of 23.5 which is within normal. FAMILY HISTORY • Patient declared that there is no heredofamilial disease on both maternal and paternal side. PERSONAL SOCIAL HISTORY • J.R is a housewife currently residing in Capitol, Cebu City, Cebu with her husband for 14 years and her two children aged 12 y.o and 10 y.o, a girl and boy, respectively. Her husband is a carpenter, who is the sole provider in the family. Patient is a nonsmoker and non alcohol drinkers. She eats 3 meals per day with a 2,100 kcal daily. She prefers meals which include vegetables, fruits and meat usually fried. She usually drinks 2-3 glasses of mineral water, but after the edema on his both feet progresses he is scared to drink more mineral water and chose to drink only 3-4 glasses. She admits to be fond of eating junkfoods. There was no history of drug abuse. PERTINENT FINDINGS IN MEDICAL HISTORY PERTINENT FINDINGS PERTINENT (+) 35 years old Female Easy Fatigability Body Malaise G2P2(2002) Poor compliance on iron supplements diet is around 2100 kcal per day. Her recommended daily caloric intake is 2400 kcal which net her a caloric deficit of about 300 kcal PERTINENT (-) BP within normal limits No change in bowel movement No dizziness No shortness of breath No vomiting NSVD on first 2 childbirths No complications on her first 2 child births Non-hypertensive Non-asthmatic No food and drug allergies No history of recent Travel No psychiatric history No history of drug abuse REVIEW OF SYSTEMS REVIEW OF SYSTEMS ORGAN SYSTEMS PERTINENT POSITIVE (+) GENERAL SURVEY • Weight change: gained 6 Kg in her entire course of pregnancy SKIN HEENT PERTINENT NEGATIVE (-) • (-) Varicose Veins Clots in veins • No significant findings. No rashes • • • • • No significant findings No headache No visual changes No ear or nose discharge No thyroid problem REVIEW OF SYSTEMS ORGAN SYSTEMS NECK PERTINENT POSITIVE (+) PERTINENT NEGATIVE (-) • No significant • No lump or tenderness in the neck BREAST • Usually breastfeed her newborn RESPIRATORY • No shortness of breath • No colds/cough CARDIOVASCULAR • No significant findings • No edema REVIEW OF SYSTEMS ORGAN SYSTEMS GASTROINTESTINAL PERIPHERAL VASCULAR URINARY PERTINENT POSITIVE (+) • Likes to eat junkfood PERTINENT NEGATIVE (-) • Does not have appetite for vegetables and fruits • No nausea • No vomiting • No change in bowel movement • No significant findings • No edema • • • • No significant findings No pain in urination No urinary incontinence No blood in urine REVIEW OF SYSTEMS ORGAN SYSTEMS GENITALIA MUSCULOSKELETAL PERTINENT POSITIVE (+) PERTINENT NEGATIVE (-) • PAP Smear screening (2019) Normal • No significant findings • Body malaise all over the body Thank You Stay safe and God speed DOC! SANJAY SINGHANIA