XAVIER UNIVERSITY IV.

HISTORY OF FAMILY
ATENEO DE CAGAYAN  HYPERTENSION
OBSTETRIC ASSESSMENT TOOL o CORONARY ARTERY DISEASE
o CEREBRO-VASCULAR DISEASE
 DIABETES MELLITUS
I. GENERAL INFORMATION o KIDNEY DISEASE
NAME: JDL AGE: 33 BIRTHDAY: 3/25/86 o TUBERCULOSIS
CIVIL STATUS: MARRIED SEX: F RELIGION: ROMAN CATHOLIC o CANCER
OCCUPATION: TRAFFIC AID ADDRESS: #0930 PIAPLNG MACABALAN, V. OBTETRIC HISTORY
CAGAYAN DE ORO CITY, MISAMIS ORIENTAL PARA: 2 GRAVIDA: 2 TPAL: 2-0-0-2
INFORMANT: MON VINCENT LABALAN RELATION: HUSBAND PRENATAL CARE COVERAGE: PRENATAL VITAMINS
ADMISSION DATE: 7/21/19 TIME: 10PM PLACE OF PRENATAL CARE: MRXUH
CHIEF COMPLAINT: LABOR PAINS TOTAL NUMBER OF VISITS: 8 AND MORE
ATTENDING PHYSICIAN: DR. RICO BORROMEO ABNORMAL FINDINGS: -
DIAGNOSIS/IMPRESSION: PREGNANCY FULL TEM CEPHALIC PRE-PREGNANCY WEIGHT: 47KG
INLABOR FEMALE NEONATE WEIGHT GAIN: 4.5KG
II. HISTORY OF PRESENT ILLNESS: LAST MENTRUAL PERIOD: OCT. 11, 2018
PATEINT RECEIVED AMBULATORY, NON-DYSPNEA WITH EDC: JULY 18, 2019
COMPLAINTS OF BROWNISH VAGINAL DISCHAGRE. INTERNAL AGE OF GESTATION: 38 WEEKS
EXAMINATION DONE BY MIDWIFE, 10 MINUTES LATER BOW ACTUAL DATE OF DELIVERY: 7/21/19 TIME: 11:19PM
RUPTURED TYPE OF DELIVERY: NORMAL SPONTANEOUS VAGINAL DELIVERY
CURRENT MEDICATIONS: POSITION OF FETUS: CEPHALIC PRESENTATION
NAME, DOSE TIMING, ROUTE INDICATION COMPLICATIONS OF LABOR: -
ONSET AND DURATION OF LABOR: 3HRS
CEPHALEXIN 500MG CAP q8h SKIN AND GENITOURINARY EPISIOTOMY: MEDIAN LOCHIA: RUBRA AMOUNT: 250ML
INFECTION COMPLICATIONS OF PREGNANCY: -
TDL+ PCM P.O q8h MODERATE TO SEVERE ACUTE EXCESSIVE BLEEDING: -
PAIN INFECTIONS: -
SENOKOT FORTE 1 TAB HS P.O LAXATIVE INFANT’S APGAR SCORE: NOT ON CHART
PLANS FOR FEEDING: EXCLUSIVE BREASTFEEDING FOR 6 MONTHS

UPON ASSESSMENT:
VI. GYNECOLOGIC HISTORY
VITAL SIGNS: HR: 68BPM RR: 22BPM BP: 120/80 TEMP: 36
AGE OF MENARCHE: 12
Ht: 5’2 Wt: 61.5KG BMI: 24.8
MENSTRUAL CYCLE:
INTERPRETATION OF BMI: NORMAL WEIGHT
INTERVAL/LENGTH: 28
III. PAST OBSTETRIC/MEDICAL/SURGICAL HISTORY
DURATION OF FLOW: 5
UN 2ND TRIMESTER OF PREGNANCY
AMOUNT OF FLOW: MODERATE
MENSTRUAL DISCOMFORT: DYSMENORRHEA
VAGINAL DISCHARGE: NO SMELL, MILKY WHITE COLOR
BLEEDING BETWEEN PERIODS: - EYES/EARS
SEXUALLY ACTIVE: YES SEXUAL DIFFICULTIES: -
RECENT CHANGE IN INTEREST/FREQUENCY: - OBJECTIVE:
REPRODUCTIVE TRACT SURGERY: - EDEMA IN EYELIDS NONE
FAMILY PLANNING METHODS USED: NATURAL- CALENDAR METHOD SCLERA AND CONJUCTIVA: PINK AND MOIST
FOR HOW LONG: 8 YEARS SPOTS BEFORE THE EYES: NONE
SIDE EFFECTS IF ANY: - DOUBLE VISION: NONE
PREVIOUS MISCARRIAGES/ABORTION: NONE SUBJECTIVE
VII. ASSESSMENT OF SYSTEMS
OBJECTIVE NOSE
GENERAL APPEARANCE AND MENTAL STATUS: ALERT, WELL NASAL CONGESTION: NONE
GROOMED, INTERESTED SENSE OF SMELL: ABLE TO SMELL WELL
PERSONAL HYGIENE: WELL KEPT EPISTAXIS: NONE
HAIR: STRAIGHT, EVENLY DISTRIBUTED
CLOTHING/ MANNER OF DRESS: MOUTH, TEETH AND THROAT
BODY ODOR: NONE OBJECTIVE
SKIN INTEGRITY: INTACT, NORMAL TURGOR CONDITION OF MOUTH: HEALTHY NO LESIONS
SPEECH: CONDITION OF TEETH AND GUMS: NO CAVITIES, PINK GUMS, NO
 CLEAR LESIONS
o UNINTELIGABLE APPEARANCE OF TONGUE: PINK, MOIST, NO LESIONS
o SLURRED LESIONS: -
o APHASIC DENTAL HYGIENE: GOOD HYGIENE
SUBJECTIVE DENTAL CARRIES: -
PAIN:
PRECIPITATING: “SAKIT SA TAHI” NECK/ LYMPH NODES
QUALITY: “KANA MURAG STRETCHING” OBJECTIVE
LOCATION: PERINIAL AREA SEVERITY: 5 OUT OF 10 THYROID HYPERTROPHY: -
TIME: “WHEN MOVING” PALPABLE LYMPH NODE: CERVICAL LYMPH NODE PALPABLE

HEAD AND SCALP BREAST

SYMMETRY: SYMETRIC OBJECTIVE/SUBJECTIVE
CONTOUR: SMOOTH DISTRIBUTION: EVEN BREAST CHANGES:
THICKNESS: MODERATE DRYNESS/OILINESS: OILY AREOLA: LARGER, DARKER
USE OF HAIR DYE: - BREAST SIZE: ENLARGED
LESIONS: - PRESENCE OF COLOSTRUM: YES
SUBJECTIVE ADEQUACY OF BREAST FOR BREASTFEEDING: NOT ENOUGH MILK
HEADACHE SEVERITY: - LOCATION: - FREQUENCY: - PRODUCED
DIZZINESS: - ABNORMAL SIGNS: INVERTED NIPPLE
WEAKNESS: - PERFORM BSE (FREQUENCY AND SCHEDULE): 1X A MONTH
ABDOMEN ELIMINATION
OBJECTIVE (ANTEPARTUM) USUAL BOWEL PATTERN: EVERYDAY
FUNDAL HEIGHT: 38CM CHARACTER OF STOOL
LEOPOLD'S MANEUVER: RIGHT OCCIPUT ANTERIOR AMOUNT: ONE CUP
FETAL POSITION: CEPHALIC COLOR: BLACK
PELVIC MEASUREMENT: 12CM GYNECOID FREQUENCY: ONCE A DAY
ODOR: FOUL
CIRCULATION USUAL VOIDING PATTERN: 3X A DAY
ANKLE/LEG EDEMA: - PAIN WHEN VOIDING: -
HISTORY OF HYPERTENSION: - HISTORY OF KIDNEY DISEASE: -
EXTERMITIES: NUMBNES: - TINGLING: -
CHANGE IN FREQUENCY/AMOUNT OF URINE: INCREASE IN ACTIVITY AND REST
FREQUENCY HOBBIES: “LIMPYO SA BALAY”
HOMAN'S SIGN: NEGATIVE LEISURE TIME ACTIVITIES: “TAN.AW TV”
SLEEP
OBJECTIVE # OF HOURS: 8HRS NAPS:30 MIN
BP: 120/80 FEELING ON AWAKENING: “OKAY RA”
HEART RATE: 68BPM DIFFICULTY IN SLEEPING: -
CAPILLARY REFILL: <2SECONDS
COLOR: PINK EGO INTEGRITY
CYANOSIS/PALLOR: - SUBJECTIVE
VARICOSITES: - REPORT OF STRESS FACTORS: WORK
NAIL BEDS: CONVEX, SMOOTH, SHINNY WAYS OF HANDLING STRESS: “PAHANGIN, MUGAWAS SA OFFICE”
MUCOS MEMBRANES: MOIST, PINK, NO LEISIONS FINANCIAL CONCERNS: NONE
RELATIONSHIP STATUS: MARRIED
RESPIRATION: LIFESTYLE: ACTIVE
OBJECTIVE HELPLESSNESS, HOPELESSNESS, POWERLESSNESS: NONE
RR: 22BPM
DEPTH: NORMAL EMOTIONAL STATUS: CALM
SYMMETRY: SYMETRIC
SMOKER: NO SAFETY
SUBJECTIVE
FOOD/ FLUID INTAKE ALLERGIES: -
USUAL DIET: REGULAR DIET HISTORY OF STD: -
NO. OF MEALS: 3X A DAY
LAST MEAL INTAKE: BREAKFAST SOCIAL INTERACTIONS
NAUSEA: - SUBJECTIVE:
MARITAL STATUS: MARRIED
YEARS IN A RELATIONSHIP: 8YEARS
LIVING WITH: HUSBAND BODY MAP
EXTENDED FAMILY: NONE
ROLE WITHIN THE FAMILY: WORKING MOTHER AND WIFE

TEACHING/LEARNING
SUBJECTIVE
DOMINANT LANGUAGE: “ OO, BISAYA”
LITERATE: YES
EDUCATIONAL LEVEL: TERTIARY

DEVELOPMENTAL MILESTONE
AGE PSYCHOSEXUAL PSYCHO- COGNITIVE
SOCIAL

32 Y/O GENITAL INTIMACY VS FORMAL

-SEXUAL ISOLATION OPERATIONAL
RELATIONSHIPS -ESTABLISHING -ABLE TO
BONDS AND THINK
RELATIONSHIPS ABSTRACTLY
AND
CRITICALLY

LEGEND:

Episiotomy
IVF (D5LR) on left hand
Linea Negra