Answered: WRITE THE PRESENT HISTORY ILLNESS AND…

Phlebotomy Essentials

6th Edition

ISBN:9781451194524

Author:Ruth McCall, Cathee M. Tankersley MT(ASCP)

Publisher:Ruth McCall, Cathee M. Tankersley MT(ASCP)

Chapter1: Phlebotomy: Past And Present And The Healthcare Setting

Section: Chapter Questions

Problem 1SRQ

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Question

WRITE THE PRESENT HISTORY ILLNESS AND PAST HEALTH HISTORY BASED FROM THE SCENARIO

Transcribed Image Text:CASE SCENARIO Date: August 23, 2022 Interviewed by: OB Clinical History GENERAL DATA: R.L, 26y/o, Gravida 2 Para 1 (1001), presently residing at Brgy. 200 Marianas City seen for prenatal checkup. PATIENT'S PROFILE: Date of Birth: July 10, 1993 Occupation: None Birthplace: Havanas City Non-smoker; non-alcoholic beverage drinker CHIEF COMPLAINT: FOR PRENATAL CHECK-UP HISTORY OF PRESENT ILLNESS: LMP: December 25, 2021 PMP: November 25, 2021 EDC: October 1, 2022 Informant: Patient Reliability: 80% Status: Single Attitude: Cooperative Religion: Catholic Availability of Relatives: nearby AOG x LMP: 34 weeks and 3 days FIRST TRIMESTER: The patient experienced cessation of menses, nausea and vomiting, breast tenderness and urinary frequency at January 2021, but did not experience easy fatigability. Self-pregnancy test was done on the 2nd week of the 1st month of missed menses (January, 2021) which revealed positive result. She consulted a private obstetrician where CBC, urinalysis and 75gOGTT were requested and revealed normal results. Transvaginal ultrasound revealed single intrauterine pregnancy compatible to 11weeks 1day age of gestation (March 2021). She had clear vaginal discharge, non-foul smelling. No laboratory request was requested. She was given GynePro feminine wash for 2 weeks, multivitamins, Ferrous sulfate and folic acid 1 tablet once a day which she took regularly. She denies any history of accidents, trauma, illness, or any exposure to radiation or toxic chemicals. SECOND TRIMESTER: Quickening was felt on the 5th month of pregnancy (May, 2021). She had regular intake of Multivitamins 1 tablet once daily, Ferrous sulfate 1 tablet once daily and Calcium 1 tablet once a day. Transabdominal ultrasound for age determination was done on the 7th month of pregnancy revealing single, intrauterine pregnancy compatible to 28weeks and 6days age of gestation (July, 2021). Patient had regular prenatal check-ups. She denies any history of accidents, trauma, illness, or any exposure to radiation or toxic chemicals. THIRD TRIMESTER: Subsequent prenatal check-ups were every 2 weeks as well as regular intake of Multivitamins 1 tablet once a day, Ferrous Sulfate 1 tablet once a day and Calcium tablets once a day. She had no subjective complaints such as hypogastric pain, abnormal vaginal discharge, vaginal spotting, dysuria, fever, cough and colds. She denies any history of accidents, trauma, illness, or any exposure to radiation or toxic chemicals. The patient is scheduled for Low Segment Cesarean Section on September 23, 2022. She experienced crampy, intermittent, hypogastric pain non-radiating. No other associated signs and symptoms such as nausea/vomiting, body malaise and fever. Sought consult at our institution and was subsequently admitted.