FORM NO.

IIFb-26
Republic of the Philippines
Department of Health
JOSE R. REYES MEMORIAL MEDICAL CENTER
Department of Obstetrics and Gynecology
RESIDENTS 24-HOUR OB-GYNE HISTORY
DATE: October 25, 2015
HOSPITAL NO.: 2015046552
ATTENDING PHYSICIAN: Dr. Cole/Alvarina/Brazal,
Soriano/Barcial
----------------------------------------------------------------------------------GENERAL DATA
NAME:
Bulsao,
AGE: 64
Clemencia
BDAY: 08/10/1951
CIVIL
STATUS:
Married
RELIGION: Baptist
ADDRESS: b
DATE OF ADMISSION: October 25, 2015
CHIEF COMPLAINT: For blood transfusion
HISTORY OF PRESENT ILLNESS
Patient is a known case of Squamous Cell Carcinoma,
Large cell nonkeratinizing, Cervix stage IIIB for 3 years,
S/P Total Abdominal Hysterectomy with Bilateral
Salphingo-oophorectomy (2011, Laoag) and had 3 cycles
of chemotherapy.
1 day prior to admission, patient, prior to chemotherapy,
had routine CBC and revealed a hemoglobin of 4.7. There
were no any associated symptoms like headache,
dizziness, difficulty on breathing or change in weight. No
vomiting and vaginal bleeding noted.
Few hours prior to admission, during consult, patient was
advised blood transfusion prompting admission.
PAST MEDICAL HISTORY
(-) DM
(-)Cancer
(-)Heart disease
(-)Allergies,
(-)PTB
seafood
(-)asthma
(+)HPN

amlodipine 5mg
tab
FAMILY HISTORY
(-) DM
(-)
cardiac
disease
(-)PTB

(-)Cancer
(-)asthma
(-)HPN

(-) accidents
(-)previous
hospitalizations

(-) liver disease

(-)
kidney
disease
(-) lung disease
(-) allergies to
food or drugs

PERSONAL AND SOCIAL HISTORY:

(-) smoker,
(-) alcoholic beverage drinker
(-) illicit drug use.
Yea
r

Place

Gend
er

G1

197
6

Home

Live,
full
term,
baby
boy
Live,
full
term,
baby

G2

198
1

Home

Mann
er of
delive
ry
NSD

GYNECOLOGIC HISTORY
M: 17 years old
I: irregular
D: 4 days
A: 3 pads per day, fully soaked
S: (-) dysmenorrhea, (-) dyspareunia, (-) post-coital
bleeding, (-) leucorrhea, (-) exposure to sexually
transmitted disease
(-) chronic pelvic pain
(-) Foul-smelling discharge
METHOD OF CONTRACEPTION
None
SEXUAL HISTORY
The patient had her coitarche at 22 years old and has
had 1 sexual partner since.
PHYSICAL EXAMINATION
General Survey: Patient is conscious, coherent, not
in cardiorespiratory distress, with the following vital
signs.
BP: 120/80 PR: 88 bpm RR: 20 cpm Temperature:
36.5 oC
HEENT: Anicteric sclera, pink palpebral conjunctivae,
no nasoaural discharge, no tonsillopharyngeal
congestion
Neck: Supple neck, no neck vein engorgement, no
cervical lymphadenopathy.
Chest: Symmetrical chest expansion, no retractions,
no lagging
Lungs:
Clear breath sounds, no crackles, no
wheezes.
Heart: Adynamic precordium, normal rate, regular
rhythm, no murmur
Breast: Symmetrical contour, no dimpling, no
papable mass, no tenderness, no abnormal nipple
discharge
Abdomen: flabby abdomen, normoactive bowel
sounds, nontender
Speculum Exam: not done
Internal Exam: not done
Extremities: grossly normal extremities, full equal
pulses, no edema
Skin: no active dermatoses

BW

Complicati
ons

ASSESSMENT:
Gravida 2 Para 2 (2001) Squamous Cell Carcinoma,
Large cell nonkeratinizing, Cervix stage IIIB, S/P Total
Abdominal Hysterectomy with Bilateral Salphingooophorectomy (2011, Laoag); Anemia severe

AG
A

None

PLAN:

Gravida 2 Para 2 (2001)

Gravi
da

boy

For correction of anemia

NSD

JRRMMC-F-OBG-IIF-20
Page 1 of 1

AG
A

None

October 10, 2015

Revision No.: 0