FORM NO.

IIFb-26
Republic of the Philippines
Department of Health
JOSE R. REYES MEMORIAL MEDICAL CENTER
Department of Obstetrics and Gynecology

RESIDENT’S 24-HOUR OB-GYNE HISTORY

DATE: August 11, 2019 Gravida 3 Para 3 (3003)
HOSPITAL NO.: 2019072642 GRAVITY OUTCOME ROUTE PLACE OF BIRTH COMPLICATIONS
YEAR DELIVERY WEIGHT
ATTENDING PHYSICIAN: Dr. Valencia/ Cuenco, Corpuz/ FULE/
G1 Live, term, CS (CPD) Fabella Unrecalled None
Magdaluyo, Perez/ Cariño, Cabana 1980 male Hospital
------------------------------------------------------------------------------------ G2 Live, term, CS Fabella Unrecalled None
GENERAL DATA: 1985 male (repeat) Hospital
Name: BUENDIA, CRISTINA Age: 55 G3 Live, term, CS Fabella Unrecalled None
OBRIQUE 1987 male (repeat) Hospital
Civil Status: Married Birth date: April 13, 1964
Religion: Catholic PHYSICAL EXAMINATION:
Address: B19 L34 GPL2 Malagasang, Imus, Cavite General Survey: Patient is conscious, coherent, not in
cardiorespiratory distress with the following vital signs
CHIEF COMPLAINT: BP: 130/70mmHg CR: 87 bpm RR: 18 cpm T: 36.3 C
Vaginal bleeding HEENT: Anicteric sclera, pink palpebral conjunctiva, no nasal and aural
discharge, no tonsillopharyngeal congestion, no cervical
HISTORY OF PRESENT ILLNESS lymphadenopathy, no neck vein engorgement
One day prior to admission, patient noted vaginal bleeding Chest and Lungs: Symmetrical chest expansion, no retractions, with
amounting to 1 fully soaked adult diaper. Patient was then brought to clear breath sounds, no crackles, no wheezes
Ospital ng Imus ER Department where CBC and ABO/Rh were done. Heart: Adynamic precordium, normal rate, regular rhythm, no murmur
Patient was given O2 support, intravenous fluid, and tranexamic acid. Abdomen: Flabby, normoactive bowel sounds, no tenderness
In the interim, patient still had persisted vaginal bleeding Speculum Exam: Not done
amounting to 3 fully soaked adult diapers. Internal Exam: Cervix effaced by a 5x5 cm mass, corpus enlarged 3
months size, (+) bleeding, no adnexal masses
PAST MEDICAL HISTORY: Extremities: Grossly normal extremities, no deformities, no cyanosis,
(-) HPN (-) Thyroid disease no edema
(-) Heart disease (-) Liver disease
(-) DM (-) Kidney disease ASSESSMENT:
(-) PTB (-) Prev operation Gravida 3 Para 3 (3003) Abnormal Uterine Bleeding, To Consider
(-) Asthma Leiomyoma, To Consider Cervical Carcinoma; Anemia – Severe

PLAN:
FAMILY HISTORY: For Correction of Anemia
(-) Malignancy (-) Asthma
(+) HPN – maternal (-) Thyroid disease
(-) Heart Disease (-) Liver disease
(-) DM (-) Kidney disease
(-) PTB

PERSONAL AND SOCIAL HISTORY:

(-) Smoker
(-) Alcoholic beverage drinker
(-) Illicit drug use
(-) Allergy to food
(-) Allergy to drugs

Educational Attainment: Elementary

Employment: None

MENSTRUAL HISTORY:
Menarche: 13 years old
Interval: 28-30 days
Duration: 3-4 days
Amount: 4 pads per day, moderately soaked
Symptoms: (+) dysmenorrhea

GYNECOLOGIC HISTORY:
(-) Dyspareunia (-) Post Coital Bleeding
(-) Chronic Pelvic Pain (-) Foul-smelling discharge

SEXUAL HISTORY:
First Sexual Contact: 14 years old
Number of Sexual Partners: 2
Contraceptive: Tubal ligation (1987)

OBSTETRIC HISTORY:
LMP: Menopause at 53 years old

JRRMMC-F-OBG-IIF-20 August 3, 2016 Revision No.: 0 Page 1 of 1