Republic of the Philippines

North Eastern Mindanao State University

Formerly Surigao del Sur State University
Tandag City, Surigao del Sur Telefax No. 086-
214-4221
086-214-2723 www.sdssu.edu.ph

SCHOOL OF MIDWIFERY EDUCATION

PATIENT’S DEMOGRAPHICAL PROFILE

PATIENT INFORMATION:

Name: Patient 1

Civil Status: Married

Address: P-6 Barangay Adlay Carrascal, Surigao Del Sur

Religion: Catholic

Date of Birth: 08/25/1994

Age: 28

Nationality: Filipino

CURRENT HEALTH STATUS/GENERAL SURVEY

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Number of Trimester: 3 trimester
OB score: G1 P0

Vital signs:
BP: 123/72mmHg T: 36.9 PR: 93 bpm FHR: 130 bpm RR: 22 cpm

Height: 148cm Weight: 80kg

Date of Admission: 05/24/23 FP Method used:NONE

Patient’s behavior: Responsive

CHIEF COMPLIANT: Labor pain.

HISTORY OF PRESENT ILLNESS/OB HISTORY:

• Few hours prior to admission (PTA) onset of watery vaginally

discharge associated with labor pain.

PAST HEALTH HISTORY

• No history of Tuberculosis, Epilepsy, Asthma

• No history suggestive of any cardiac ailments.
 • No history of previous surgeries, blood transfusions.

CURRENT MEDICATION WITH INDICATION:

Allergies: No history of allergies to food, dust, or medication

Family History: hypertension in maternal side

Present pregnancy:
● morning sickness
● Leg cramps

LMP – 8/18/22
EDC – 5/25/22
Physical examination:

Here is a pregnant lady 28 years old, moderately built and nourished,

conscious, alert & cooperative.

Systemic examination:

● VITAL SIGNS: BP:123/72 RR:22 PR:93 Temperature:36.t9

● Skin and extremities: Grossly normal (meaning - we do not see anything abnormal)

● HEENT: Anicteric Sclera

● CHEST/LUNGS: Equal chest expansion, Clear breath sounds

● CARDIOVASCULAR SYSTEM: Regular Cardiac rate and depth

● ABDOMEN: FH-30, FHT 147

● GU (genitourinary): IE >2cm; 40%, RBOW, Cephalic

● NEURO EXAMINATION: No deficit