GENERAL DATA

SUBJECTIVE DATA
Personal and Social History
Patient was born and raised in Batac Ilocos Norte. She lives in a bungalow type of house made of concrete with 3
rooms shared by 2 families composed of 8 members. He shares a room with 2 other family members. They get their
drinking water from a water refilling station while the water for their everyday comes from NAWASA. They have a
latrine type of toilet inside their house. They use gas stove for cooking. They also have a pet dog that freely goes
inside their house. Her, 17 year old partner lives separately but visits once a week and whenever there is an
occasion.

Patient is a grade 11 student but stopped due to her pregnancy. Her partner works as a part time construction worker.

Patient is 1 pack year history of cigarette smoking (3-4 sticks/day). She started when she was 13 years old but
stopped when she learned that she was pregnant (17 years old). She drinks gin mixed with lime flavoured juice
occasionally around 2-3 times/ month she started when she was also 13 years old. She also stopped drinking alcohol
when she learned that she was pregnant. Patient denied use of illicit drugs.

Her typical diet comprise of 2 cups of whole grain rice, 1 bowl/ serving of meat and vegetable. She drinks water
liberally. She consumes 1 cup of coffee during the morning and 3 glasses of milk all throughout the day, usually
during meal time.

No known allergies.

She can do her ADLs independently. She considers walking and doing household chores as her exercise. She sleep
10 hours per day and takes a 1 hour nap in the afternoon.

Review of Systems
General: (+) easy fatigue, (-) weight loss (-) Fever
Skin: (-) pruritus, (-) rashes, (-) changes in hair/nails (+) melasma (+) Linea nigra (+) striae gravidarum
Head: (-) Headache (-) Dizziness (+) Lightheadedness
Eyes: (+) blurring of vission, (-) pruritus, (-) discharge, (-) inflammation, (-) glasses
Ears: (-) hearing loss, (-) tinnitus, (-) discharge (-) earaches
Nose, Throat, Mouth: (-) abnormal olfaction, (-) dental carries, (-) gingivitis, (-) dysphagia/odynophagia, (-)
tonsillitis, (-) hoarseness (-) gumbleeding (-) colds (-) nasal stuffiness (-) itching (-) nosebleed
Neck: (-) goiter, (-) cervical lymph node enlargement (-) mass (-) lumps (-) sore throat
Respiratory: (+) cough (+) sputum, (+) difficulty of breathing, (-) night sweats (-) pleuritic pain (-) hemoptysis
Breast: (-) pain (-) mass (-) tenderness, (+) discharge
Cardiovascular: (-) bilateral pitting edema on the lower extremities, (-) orthopnea, (-) palpitations, (-) chest pains, (-)
paroxysmal nocturnal dyspnea
Gastrointestinal: (-) decreased appetite, (-) constipation, (-) nausea (-) vomiting (-) dysphagia, (-) hemorrhoids (-)
diarrhea (-) heartburn (-) dysphagia (-)black /tarry stool (-) bloody stool (+) abdominal pain – uterine contractions/
fetal movements
Urinary: (+) frequency, (-) hesitancy, (-) dribbling, (-) pain, (-) urgency (-) hematuria (-) norcturia (-) hernia
Genitourinary: (-) loss of libido, (-) sexual dysfunction, (-) lesions, (+) discharge - leukorrhea
Peripheral Vascular: (-) edema , (-) pruritus (-) intermitted claudication (+) leg cramps (-) varicose veins
Musculoskeletal: (-) muscle weakness, (-) swelling due to edema, (-) wasting/atrophy, (-) pain, (-) fractures, (-)
stiffness, (+) joint pains
Hematopoietic system: (-) anemia, (-) abnormal bleeding (-) easy bruising
Endocrine: (-) DM indicators- polyphagia, polydypsia, polyuria, weight loss; (-) goiter, (-) heat/cold intolerance
Nervous: (-) slowed movement, (-) vertigo, (-) falls, (-) headache, (-) loss of consciousness
Psychiatric: (-) depression, (-) sleep disorders, (+) mood swings, (-) hallucinations
 OBJECTIVE DATA

Musculoskeletal
Full range of motion in all upper and lower extremities. No evidence of joint swelling or joint deformity. Lumbar
vertebrae exaggeratedly lordotic

Peripheral Vascular
No cyanosis and clubbing noted. No varicosities in both lower extremities. No edema noted. No ulceration. No
venous stasis. The pulses are full and regular and equal on all extremities. Capillary refill of less than 2 seconds.

Radial Brachial Femoral Popliteal Dorsalis Poterior tibialis

pedis
RT 2+ 2+ 2+ 2+ 2+ 2+
LT 2+ 2+ 2+ 2+ 2+ 2+

Neurologic Exam

Mental status
Patient awake, alert, oriented to time, place, person, can maintain eye to eye contact. GCS 15, Right handed

Cranial nerves
I – Not assessed
II – Visual acuity OD: 20/20 OS:20/20, PERRLA 3mm. (+) pupillary reflex. Visual field intact. Red orange reflex
present. Disc margin sharp via fundoscopy. No hemorrhages, no exudates, no lesions.
III, IV, VI – normal EOM, no nystagmus, no oscillopsia, no ptosis
V – No motor deficits, no wasting, symmetric, intact pain, touch and temperature sensation. (+) corneal reflex
VII – Symmetric facial expression, no motor deficits.
VIII – Gross hearing intact via whisper voice test. Weber test lateralize to AU. Rinne test AD: AC>BC AS: AC>BC.
IX, X – Voice is muffled and soft. Gag reflex diminished
XI – Strength of trapezius-R: 5/5 L:5/5. Strength of sternocleidomastoid- R:5/5 L: 5/5
XII – tongue midline, mobile, strength 5/5. No atrophy, no fasciculations.

Motor
No involuntary muscle movements. Normal muscle bulk. Normal muscle tone in all upper and lower extremities.
Strength in right biceps, triceps, iliopsoas, gluteals, quadriceps, hamstrings, and ankle flexor and extensor muscles
5/5; strength comparable muscle groups on the left. No dysdiadokinesia, no dysarthria, no dysmetria, no hypotonia.
Stance and Gait were not able to assess.

Sensory
Intact bilaterally for pain, and light touch. Vibration and joint position sense intact.

Reflex
Biceps Triceps Bachioradialis Patellar Achilles Plantar
RT 2 2 2 Not elicited 2 
LT 2 2 2 Not elicited 2 
 ASSESSMENT
AGE
c/o Kned

PLANNING

Diagnostics
Clinical Chemistries
Rationale
Complete blood count  RBC count will give information regarding
patient’s response to iron therapy for IDA
 WBC count with differential count will give
information as to whether her acute diarrhea is
inflammatory or infectious in origin
o An increase in total WBC count denotes
infection
o An increase in neuterophils denotes
bacterial infection
o An increase in lymphocytes denotes viral
infection
o An increase in eosinophils denotes
parasitic infection
Serum Electrolytes for Na, CL, K, HCO3  To be able to assess serum electrolyte deficits
 To be able to assess anion gap
Fecalysis  To be able to assess likely pathogen causing
diarrhea
 To assess presence of microscopic heamtochezia
CRP and ESR  An increase to these parameters suggest bacterial
infection

Maternal-Fetal Well being

Rationale
Ultrasound  To assess fetal well being
CTG  BSP provides information regarding general state
health of the fetus

Bedside Monitoring
Rationale
Vital signs  Assess degree of dehydration
SaO2  Assess response to fluid therapy
Daily Weight
Intake and Output

Therapeutics

Rationale
Secure consent for care
 Admit under OB/GYNE service
IVF: D5 O.3 NSS 1L x 6 hours  Replacement therapy to correct moderate
dehydration
Diet: Initially NPO until vomiting subsides. Progress to  Provide adequate nutrition to the mother and the
soft diet to BRAT diet to DAT fetus for growth and development
REE: 1,951 kcal
Third gen cephalorporins  Empirical Antibacterial agent for common gram
negative enteric bacteria causing AGE
KCl tablets  Acute diarrhea usually accompanies hypokalemia
Bacillus clausi  Replenish normal intestinal flora

Educative
Rationale
Frequent hand washing  To deter the spread of microorganism
Vigilance in choosing places to eat  To avoid future recurrence

REFERRAL
Refer to Obstetrics and gynaecologist for further evaluation and co-management
Refer to Pediatrics for co-management