Beruflich Dokumente
Kultur Dokumente
a. GENERAL INFORMATION
NAME: XXX
AGE: 32 years old
SEX: Female
ADDRESS: Phase 2 Ruby St. Mary Homes Subd., Brgy. Molino, Bacoor, Cavite
BIRTHDATE: August-13-1971
CIVIL STATUS: Married
DATE OF ADMISSION: September 29, 2015
TIME OF ADMISSION: 12:20 P.M
CHIEF COMPLAINTS: Labor with Contraction
INITIAL DIAGNOSIS: G4P3; Normal Spontaneous Delivery accompanied by
Pre-Eclampsia
FINAL DIAGNOSIS: Normal Spontaneous Delivery with Episiorraphy
b. OBSTETRICAL HISTORY
LMP-January 15, 2015
EDD- October 27, 2015
T-3
P-0
A-0
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L-3
Previous Pregnancy-3
Caesarean Section- No
Still Birth-No
Post-Partum Hemorrhage- No
3 Consecutive Miscarriages- No
Tetanus
1st dose
2nd dose
3rd dose
4th dose
5th dose
Toxoid
Date
2008
2008
2012
2013
July 20,
2015
66kg. During the entire of her pregnancy she has not complained for the vaginal
discharges, urinary tract infection, fever, signs of pallor and her laboratory results is ok.
On September 29, 2015 she was admitted at St. Marys Lying-In Clinic, and she
complained of labor pain. After being examined seen by her attending midwife, she has
a high blood pressure and bipedal non-pitting edema. Upon internal examination 45cms dilated of cervix, the membranes are intact, no vaginal bleeding, the contraction is
active and 5 in 10 minutes duration, the fetal heart rate was 132bpm, the temperature is
36.7oC and BP is 170/100mmHg.
e. PHYSICAL ASSESSMENT
General Survey:
Our patient, Mrs.XXX, 32 years old was assessed on September 29, 2015. She
was admitted at St. Mary Lying-In Clinic. She weighs 68kg. Patient was received
conscious, coherent and responsive. She cooperates and participates in our physical
assessment.
Vital Signs:
Date/ Time
BP (mmHg)
Temperature
(oC)
PR (bpm)
RR (bpm)
1:30 P.M
170/100
36.7
3:30 P.M
160/110
37.1
5:45 P.M
160/100
36.1
11:30 P.M
150/110
37.1
1:30 A.M
150/100
36.1
95
20
85
19
94
18
95
19
115
19
SKIN
brown skin generally uniform in color except in areas exposed to the sun
skin temperature uniform and within the normal range (37C)
when pinched, skin readily springs back to previous state
moist skin folds
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HEAD
EYES
EARS
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NOSE
outer lips uniform pink color with symmetric contour, soft and moist
buccal mucosa is of uniform pink color
gums are pink
tongue pink, moist, at central position
head centered
lymph nodes not palpable
NECK
BREAST
firm
generally symmetric in size
Engorged breast
CARDIOVASCULAR
BP 170/100 mmHg
PR 95 bpm
reported palpitations
symmetric pulse strength
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RESPIRATORY/CHEST
chest symmetric
chest wall intact, no tenderness, no masses
symmetric chest expansion and excursion
RR: 20 breaths per minute
GASTROINTESTINAL/ABDOMEN
URINARY
REPRODUCTIVE
MUSCULOSKELETAL/EXTREMITIES
NEUROLOGIC
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