VITAL INFORMATION

Name: Ms. Preggy Gender: Female Address: Ma. Christina, Balo-I, Iligan City, Lanao Del Norte Room No.: 286 6 Birth Date: December 24, 1993 Birth Place: Iligan City Age: 19 years old Marital Status: Single Occupation: Student Language: Bisaya, Tagalog and English Nationality: Filipino Religion: Roman Catholic Education: College Level (4th year) BSED Bio Date of Admission: July 28, 2013 Time of Admission: 12:55 pm Attending Physician: Maria Lilagri G. Marcella, MD Obstetrician/Gynecologist Diagnosis: Pregnancy Uterine 20 weeks, Acute Pyelonephritis Source of Information: Patient 60% SO 20% Chart 20% Reason for Seeking Care: Abdominal Pain (Right flank pain), AOG 20 weeks

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NURSING HISTORY

Menstrual History
Ms. Preggys Last Menstrual Period was on March 10, 2013. She had her first menstrual period when she was still 11 years old. Her menstrual cycle has a duration of 7 days and an interval of 26 30 days. She seldom experienced bearable dysmenorrhea during her period; no other associated symptoms. Her expected date of confinement is December 17, 2013.

Obstetric History
Ms. Preggy does her prenatal check-up at the Health Center of Brgy. Bagong Silang. She had her prenatal check up once only last June 23, 2013 and was advised to take Nutrizone OB, Ferrous Sulfate and Folic Acid. Ms. Preggy has an OB index of G1Po and has an AOG of 20 weeks.

Past Health History

Ms. Preggy had been diagnosed with asthma when she was still 1 4 years old. She was not able to recall her medications and the specific health care provider she consulted for treatment of her stated condition. According to her, her asthma went away by the time she reached 5 years old. She had also experienced chicken pox when she was 9 years old and dengue when she was 11 years old. She was hospitalized for dengue at Gregorio T. Lluch Memorial Hospital; she was unable to recall her health care provider and medications taken. She was also unable to recall her immunizations. She had experienced a jeepney accident with her family while she was still on 6th grade; she had only bumps in her head and had no injuries manifested thus, she refused to be hospitalized. She had no serious or chronic illnesses and she had no known allergies to food and medications. She was hospitalized at Chung Hua Hospital last 2009 because she experienced muscle cramps in different parts of her body and loss of consciousness. In relation to that past hospitalization, she stated that she didnt know her diagnosis but her mother told her that according to the doctor, it was due to lack of oxygen in the brain; she was prescribed with Lamictal and Folic acid. On 2010, she had experienced dysuria for 3 consecutive days; no consultations done; increased water intake, drank buko juice and took OTC sambong tablet as remedies. After 3 days with the stated remedies, dysuria went away and didnt recur. She had also not undergone any operations. Ms. Preggys current medications during hospitalization at AMC are : Pharmacet 750 mg IVTT every 8 hours, Tramal 500 mg IVTT, Cefurex 500 mg 1 Tab twice a day, Calvit Plus 1 Tab once a day, Multivitamins 1 Tab once a day and Paracetamol 500 mg 1 Tab every 4 hours for fever and pain.

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History of Present Illness

On July 27, 2013 at 10:30 am, Ms. Preggy was at their home eating breakfast and watching television when suddenly, there was an onset of sharp abdominal pain specifically at the right lower quadrant with a pain scale of 5/10, she took no medications and no consultations done. She however, tolerated the condition. July 28, 2013 9:30 am, Ms. Preggy was awaken from sleep due to persistence of pain, with a pain scale of 7/10 radiating from right lower quadrant to the back. This prompted consult and subsequent admission. Together with her mother, she went to Gregorio T. Lluch Memorial Hospital for admission but according to her, they were not entertained, thus, they decided to be admitted at Adventist Medical Center. July 31, 2013 at 4:00 pm, Ms. Preggy was discharged in good condition. She was able to comply all the medications prescribed and showed improvement in her condition as evidenced by a tolerable right flank pain with a pain scale of 3/10 and normal vital signs.

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