3p’s

PERSONAL DATA

Name: Mrs. G
Birthdate: 07 Feb 1976
Age: 43y 11m 20d
Height: 157 cm
Weight: 58kg
Civil Status: Married
Address: Villaros, Bagabag, Nueva Vizcaya
Religion: Catholic
Nationality: Filipino
Occupation: Housewife
Blood Type: O+
Husband Name: Mr. B
Occupation: Pepsi Driver
Age: 24y/o
Date Admitted: 27 Jan 2020
Admitting Diagnosis: Acute abdomen secondary to ruptured ectopic pregnancy
Principal Diagnosis: Tubal pregnancy ampullary left ruptured, 6 1/7 weeks age of gestation
Admitting Physician: Doctor E
OB History: G4P1 (1031)
LMP: 15 Dec 2019

Past Health History:

Mrs. G is currently living with her husband named Mr. B. He is 24 years old. Mrs. G said
that her family has no history of hereditary diseases that she might get, there are no also history of
abortion in their family. She also had common childhood illnesses like coughs and colds and she
is treating this by taking an oral medicine. She has no allergies to any food or medicine. The patient
only stays at home and she said that she is eating balanced meal every day that contains meat and
vegetables.

Present Health History

One day prior to admission, when Mrs. G had vaginal bleeding with hypogastric pain, no
consultation was done. On January 27, 2020 when patient is still having vaginal bleeding with
hypogastric pain, she was immediately rushed at the R2TMC 6:10PM. The client was conscious
and coherent. The client experienced sharp abdominal cramps, dizziness or weakness, no edema,
and positive tenderness in all quadrant of the abdomen noted. She also had an IE and the cervix is
close. She was admitted at the R2TMC OB Ward 6:40PM, her admitting diagnosis was acute
abdomen secondary to ruptured ectopic pregnancy. Her Vital signs was: Blood pressure: 90/70,
Temperature: 37.7 degrees Celsius, Respiration Rate: 25 Cpm Pulse rate: 116 Bpm. She had her
operation on that day also, January 27, 2020 at 9:02PM. Her Principal Diagnosis was Tubal
pregnancy ampullary left ruptured, 6 1/7 weeks age of gestation and the principal operation was
an emergency laparotomy with evacuation hemoperitoneum, salpingectomy on left under sub-
arachnoid block. The medicine ordered by the doctor was Cefixime, diclofenac, paracetamol,
nalbuphine, and ondansetron.

Obstetrical History

Mrs. G had her menarche at the age 12 years old. Her menstruation lasted for about 3 days,
according to her it was dark brown on the first 3 days and dark red for the remaining days. She has
28 days menstrual cycle; she usually consumes 3 pad a day during her monthly period. She had
her telarche at the age of 9 years old. She also stated that she had her first sexual intercourse when
she was 28 years old. She got pregnant at the age of 38, in the year 2014. According to Mrs. G,
she had her first pregnancy last 2014 and she accidentally slumped to the floor and lost the child.
On her second pregnancy last 2016 she lost again her child, she doesn’t know that she was
pregnant, until she was bleeding, that is the time when she knew that she is pregnant. On the year
2018 it was her third pregnancy she gave birth to a live baby girl with a weight of 3000grams,
AOG 37 3/7 weeks. Her GTPAL Score is G4P1 (1031).