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