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JMJ
University of St. La Salle
College of Nursing
A.Y. 2021-2022

Zamora, Barbara Ally BSN2H | Week 3 Duty

NCM107ARCE_H September, 2, 2021

3.2.2 Learning Task 2: Let's Compute and Document

Case Scenario

Patient A.R. 17 years old, single, came in the Family Planning and OB clinic
at the Out Patient Dept. of CLMMRH, accompanied by her mother for her pre- natal
check-up. Her LMP was last June 22, 2021. She has been experiencing intermittent
nausea, vomiting and dizziness. This is her first visit at the clinic. She is sexually active
with her 22 year-old partner. No history of sexually transmitted disease. She has mild
asthma for which she has a prescribed inhaler which she uses as needed. Upon
assessment her vital signs are as follows: Temp. 36.8, Pulse 82bpm, Resp. 18cpm,
Blood pressure 110/80 mmHg, Wt. 58 kg. Ht. 155 cm.

Read and understand the case scenario and do the following:

1. Fill up the Treatment record form. (in page 2)

2. Get the EDC and AOG [(First visit Aug. 18, 2021) in page 3]
 OUTPATIENT DEPARTMENT
TREATMENT RECORD AND PROGRESS NOTES

Name of patient: A.R. Age: 17 years old Sex: Female Hospital No. 2020963 .

Date Chief complaint / History Diagnosis Service/ Remarks/

Time /PE Treatment/ special
Service Type Procedure instruction
Vital Signs Rendered

August 18, 2021 Intermittent nausea, vomiting Pre- natal

8:00 AM and dizziness. check-up
Family Planning and
OB Assessment
T: 36.8 °C
PR: 82 bpm
RR: 18 cpm
BP: 110/80 mmHg
Height: 155 cm.
Weight: 58 kg.
Barbara Ally Zamora
SN-USLS

Signature
EDC & AOG (First visit on August 18, 2021)

Last Menstrual Period (LMP): June 22, 2021

Date of Admission: August 18, 2021

EDC:

LMP – 3 months + 7 days to LMP + 1 year = EDC

6 22 2021

-3 +7 +1 .

3 29 2022

= March 29, 2022

AOG:

LMP (days) Present date (admission) / 7 days = AOG

June 22, 2021 = 30 days – 22 days = 8 remaining days

June 8 8 weeks
July 31
7 ⟌57
August 18
- 56
57 / 7
1 day

= 8 weeks and 1 day