Name: Alcuran, Apple M.

Sex: female Age: 19

Birthday: June 6, 1992 Address: 400 Bigaa, Cabuyao Laguna Civil Status: Single Nationality: Filipino Religion: Catholic Hospital No. 687585 Date Admitted: November 12, 2011 Time Admitted: 10:20 pm Attending Physician: Dra. Maceda/ Dra. Gan Admitting Diagnosis: Hydatidiform Mole 13-14 weeks Age of Gestation. Anemia Secondary Chief Complaint: The patient was admitted at the Emergency Room at around 10:20pm Last November 12, 2011 for the first time due to profuse vaginal bleeding.

History of Present Illness:

The patients condition apparently started 4 days prior to admission. The patient had experienced vaginal bleeding bright red in color, in minimal amount. The patient consumed 1 pack/day, fully soaked. On 2 days prior to admission, patient consulted at PMD, pelvic ultrasound done showed Gestational Trophoblastic Disease (7.5 x8.0 x 6.6cm heterogeneous mass). She was advised to admit but no room available and the patient experiencing on and off fever. A few hours prior to admission, the patient had profuse vaginal bleeding with clots and subsequently admitted.

Past Medical History:

The patient is known asthmatic since childhood. The patient doesn t have any history of diabetes mellitus, cancer, pulmonary tuberculosis or even liver and kidney problem. She already gave birth last January 2011 via normal spontaneous delivery. The patient doesn t have any history of hypertension, cancer either. A. 1 General State of Health: weak in appearance 2 Childhood Illness: chicken pox 3 Adult Illness: Asthma attack (11/10) 4 Accident and Injuries: none 5 Operations: 6 Past Hospitalizations: B. Current Health Status 1. Allergies: none 2. Immunizations: none 3. Screening tests: Routine laboratory exams and procedures performed to determine her health status. 4. Rest and Sleep Pattern: 8-10 hours/day 5. Exercise and Leisure Pattern: household chores as form of exercise 6. Diet and Nutrition: eats all kinds of foods (vegetables, meat and fruits) 7. Smoking: (+) started 16 years old, 4-5 sticks/day and stopped 2 months ago 8. Alcohol: (+) since high school, occasionally. 9. Drugs: (-) 10. Current Medications:

Family History

NAME Domeng Rizza 1.Mark Angelo 2. Joan 3. Aisa 4. Kenneth 5. Apple 6. Coleen 7. Nicole 8. Carlos

AGE 51 50 25 27 25 22 19 12 10 8

HEALTH STATUS Normal Normal Deceased Normal Normal Normal Weak Normal Normal Normal

DISEASE/ CAUSE OF DEATH Hypertensive

Social History:
a. Home Situation: wakes up 9 a.m, does the household chores. b. Daily Life Routine: wakes up at 9 a.m, does the household chores, takes good care of her brothers and sisters, rest, watch TV, does the household chores, rest and sleep. c. Educational Attainment: high school d. Important Experiences: during high school graduation because she s the only one who reached secondary level among the other siblings. e. Patients outlook in life: To live a normal life They live at 400 Bigaa, Cabuyao Laguna, a bungalow type of house where the source of their water comes from dip well while the source of electricity they were using is gasera or sometimes candle light which cost 10.00Php/day . Her father Mr. Domeng Alcuran worked as a fruit vendor in a market while her mother Mrs. Risa Alcuran is a plain housewife having 3 boys and 5 girls. The patient and her live-in partner Kimwell Sagrado, 22 years old tricycle driver earned 300 to 500.00 Php a day. Most of the time the patient is the one who takes good care of her brother and sisters and the one who helps to her mother to do daily household tasks.