Está en la página 1de 5

PATIENTS PROFILE: Prenatal History: Ms. R.S.

a new citizen from Labac, Naic, Cavite got her first prenatal care last August 12, 2011. Her birthdate is February 22, 1991. I. Health History Family Health History o Health Status of parents and siblings

The patients mother was diagnosed with urinary tract infection (UTI) last year. No other related diseases to her other family members. Personal and Health History o Personal Characteristics

Ms. R.S., 20 years old is a pure-blooded Filipino and Tagalog and now living with her partner Mr. A.F. She doesnt smoke, taking drugs, no exercise done, seldom drinks alcohol but when she knew that she got pregnant, she stopped drinking alcoholic beverages. She relaxes everyday as stated by the patient, Araw-araw ako nagrerelax kasi medyo mabilis na din akong mapagod. Past Medical History

According to the patient, she has no known childhood diseases. She is not fully immunized; it was her first prenatal check-up that she couldnt go to the nearest clinic or RHU for the follow-up and record of her check-up. She doesnt undergo in hospitalization. No known surgery as verbalized by the patient and she

doesnt undergo into blood transfusions. No noted drug sensitivity and no known allergy.


No known diseases as stated by the patient. Menstrual History

The patient stated that she got her first menstruation (menarche) last 2002, November 1. Normal cycle of menstruation, no pain, clots and problems as

observed by the client. She void 10-13 times a day. She uses 2-3 pads of napkins every day. G2-T2-P1-A0-L2-M0. Last menstruation period was March 14, 2011, EDC was __ and AOG was __ as confirmed by the computation (Pilliteri 2006). Prepregnancy weight was 135 lbs. and pregnancy weight is 174 lbs. for a total gain of 31 pounds. Sexual History

With her understanding of sexual functions and sexual learning she stated, Kapag ganoon kasi ang naririnig ko o napag-uusapan ang natakbo sa isip ko ay nagkaka-anak o kaya naman tumatatag ang pagsasama ng mag-asawa gaya na lang namin ng asawa ko. In her attitudes towards sexuality, particularly as affected by pregnancy she stated, May mga oras talaga na pakiramdam ko nakakaapekto din ang pagsesex namin sa pagkakabuntis ko. Minsan kasi gusto ng asawa ko kaso ayoko talaga.

Pakiramdam ko kasi masusundan ulit yung anak namin, kaya ganoon na lang ang nararamdaman ko bilang isang ina. With her current sexual practices and satisfaction she stated, Noong nakaraan naming pagsesex ng asawa ko medyo nasatisfy naman ako kaso nga lang medyo alangan pa den ako sa pwepwedeng mangyari. Ayaw naman gumamit ng condom ng asawa ko, lagi na lang withdrawal kaya kinakabahan din ako. In contraceptive history and practices she stated, Nagamit ako ng pills yung ferrous fumanate yung nabibili ko. Para sa akin effective talaga. Kaso nga lang pag may namimiss akong isang araw na pag-inom talagang mataas ang tsansa ko na mabuntis gaya na lang ng nangyari sa akin ngayon. Sa paggamit naman naming ng withdrawal pagnagsesex ay masasabi kong hindi ganoong epektibo. Hindi din ako satisfied sa pwedeng ikaganda nito. Natatakot kasi ako. Minsan na din kaming

gumamit ng condom kaso ayaw ng asawa ko. Hindi din ako satisfy sa condom saka medyo may problema din sa condom minsan nasakit sa may pwerta ko. Sexually Transmitted Diseases

As stated by the patient and according to her record in the RHU and clinic, she doesnt have STD or sexually transmitted diseases. II. Pregnancy History Past Obstetric History

As stated by the patient, for her first child the year length gestation is ____. Current Pregnancy

Ms. R.S. last menstruation period was March 14, 2011. She stated that the date of her first fetal movement was last July 2011. Age of Gestation is ____ and the Expected Date of Delivery is ______. Symptoms

The patient complains that she was undergo nausea when she was in the first week of her pregnancy up to the third week of it. She void 10-13 times a day. She doesnt feel any headache, no edema noted, no constipation, no bleeding but there is an occurrence of abdominal pain twice or thrice a week since she knew that she got pregnant. She used to take paracetamol since pregnancy was began as a form of drug and medication to her headache. She stated that she was exposed to communicable diseases such as colds and cough. Illness began Subjective Data: The patient complains of feeling slightly dizzy while sitting, an increase of dizziness upon standing, and she is experiencing tinnitus whistling, ringing and loud whooshing like a jet engine in her ears bilaterally. The patient denies history of tinnitus, balance problems, or syncope. Pain scale is 3/10 in uteral and perineal areas. The patient stated she has not yet experienced any flatulence after the birth of her son. G.B. stated she already experiences the letdown (milk ejection) reflex whenever her son cries and he breastfeeds often and heartily. Objective Data: Prior to my assessment, the mother was gazing, smiling, and talking softly to her newborn and seemed slightly reluctant to give the newborn to the father in order for me to perform an assessment. The father looks tired as he holds the newborn closely and fondly. The father smiles at his son when he opens his eyes and excitedly informs his wife. The patients vital signs are WNL: oral temperature is 36.8C (98.2F), apical pulse is 60, respirations are 20, and blood pressure is

110/60. Lung sounds are clear bilaterally. The trachea is midline, respirations are regular and symmetrical on room air, and there is no use of accessory muscles. S1 and S2 are present, rhythm is regular and there are no murmurs, clicks, thrills, or heaves. Radial, femoral, popliteal, pedal pulses are 2+ bilaterally and cap refill <3 seconds on all digits. Skin is slightly pale, warm, and dry. No edema in the lower extremities bilaterally. BUBBLE-HE: Breasts are semi-soft, non-tender without any erythema or areas of increased warmth. Nipples are not inverted bilaterally. The fundus of the uterus is firm, centered, and located 1.5 finger breadths below the umbilicus. Facial grimacing and furrowed brows occur upon brief, gentle palpation of fundus. The bladder is not distended or palpable. G.B. has voided a total of 450 ml of clear, yellow urine this morning. The last bowel movement was November 16, 2006 per patient. Bowel sounds are hypoactive in all 4 quadrants. Abdomen is soft, nontender, and rounded. Lochia rubra is scant, without clots or odor. RML 2 episiotomy is intact without erythema or edema. There are no visible hemorrhoids. Homans sign is negative bilaterally. Upon gentle palpation bilaterally of the posterior lower extremities, there are no areas of warmth, tenderness or swelling. Emotional issues are G.B.s deep, deep desire to control her environment and the disappointment of not adhering to her well-researched birthing plan. The patient is bonding very well to her newborn and enjoys watching her husband bond with their newborn too.