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Elimination
Patient’s usual bowel movement is twice a week with a formed,
yellowish to brownish to dark colored stools. She urinates 5-8 times a day
with clear yellow colored urine. She does not experience pain and does
not have difficulty eliminating.
PHYSICAL EXAMINATION
3. 12 NEUROLOGIC ASSESSMENT
Patient is conscious, alert and coherent. Oriented to time, place, things
and persons. Does not have difficulty in understanding and can express self.
Patient was able to concentrate and follow instructions.
Patient’s biceps, triceps, brachioradialis, patellar and Achilles reflexes
has normal response. Patient has well-coordinated movements.
Cranial Nerves
• I – Olfactory: Patient was able to identify the different smells given
• II – Optic: Has 20/20 vision; able to read reading material; can see
objects in the periphery
• III – Oculomotor: Able to follow six ocular movements; pupil is
reactive to light and accommodation
• IV – Trochlear: Able to follow six ocular movements
• V – Trigeminal: was able to elicit blink reflex; felt deep and light
sensations; was able to clench teeth
• VI – Abducens: Able to move eyes laterally
• VII – Facial: Patient was able to smile, raise the eyebrows, frown, puff
out cheeks and close his eyes tightly; was able to
identify various tastes such as sour, sweet, bitter and
salt
• VIII – Auditory: Has a sense of equilibrium; is able to hear normal
volume of voice
• IX – Glossopharyngeal: Able to move tongue from side to side and
from up to down; able to swallow
• X – Vagus: Able to swallow; client can speak clearly
• XI – Accessory: can turn head and shrug shoulders against resistance
• XII – Hypoglossal: was able to protrude tongue; able to move tongue
from side to side and from up to down
OBSTETRIC HISTORY
Date Assessed: 5/14/09
I. Demographic Data
Patient’s name is R.B. She was born on august 25, 1992. Patient is 148
cm in height and 45.2 kg in weight.
Patient’s menarche was when she was 12 y.o. and has a menstrual
cycle of 28-30 days and lasts for 4-6 days. Patient’s current vital signs are:
BP=80/50 PR=86 RR=21 T=37.5. This is the patient’s first pregnancy and
without a history of abortion. Her last menstrual period was on October 7,
2008 and her expected date of delivery is on July 14, 2009.
The signs and symptoms of pregnancy experienced by the patient are
amenorrhea, enlargement of breasts, nausea and vomiting, fatigue and fetal
movements. She experienced quickening during her 5th month of pregnancy.
Since the start of the patient’s pregnancy, she never experienced
spotting, edema or any type of surgery but already fell twice on a 3-4 step
stair case. The patient has been receiving prenatal care since her 3rd month
of pregnancy and was given ferrous sulfate as her iron supplementation, and
was already given two doses of tetanus toxoid.
The patient had a history of dengue when she was 6 y.o and was
admitted at Cebu City Medical Center. The patient does not take meds for
illnesses because she finds it hard to swallow tablets or capsules.
The patient does not have a regular exercise; instead, she chooses to
socialize with friends during her free time. She only gets to exercise when
doing chores. Patient’s sleep during the night lasts for 9 – 12 hours hours
without disturbance. She also rests during the day for 1-2 hours. Rosella
defecates twice a week with a formed, yellowish to brownish to dark colored
stools.
Patient eats 3 meals and 2 snacks per day. During her meals, she eats
1 ½ -2 cups of rice and a serving of vegetables, pork, chicken, beef or fish.
And for her snacks, she eats bread paired with juice or softdrinks. The patient
does not have difficulty eating and does not have a history of eating
disorders. The patient has gained 3-5 kg since her pregnancy.
According to Patient, she started having sex when she was 15 y.o. She
and her boyfriend have sex once a week before she got pregnant. But since
her pregnancy, she and her partner ceased having sexual contact. The
patient admits of never being able to use any form of contraception and this
led to her early pregnancy. The patient does not have alternative practices
for sexual satisfaction and would not specify their positions during sexual
intercourse.
According to Patient, the pregnancy was not planned. When she found
out about her pregnancy she was not worried because this would not serve
as a hindrance for her she already is a ‘tambay.’
According to the patient she is ready to become a mother and is not
worried about finances because her boyfriend has an irregular job of boiling
‘guso’. And her boyfriend’s parents would also finance for her and her child.
Her only concern for now is for a safe delivery.
The patient no longer has her mother and was formerly living with her
father and siblings. According to Patient, her father got upset when he found
out about her pregnancy but still gives her some advices and still visits her
once in a while.
FAMILY ASSESSMENT
INITIAL DATA BASE
Both Patient and husband are minors. Husband has an irregular job
boiling ‘guso’ and has an income of P100-150 per day; while Patient stays at
home. Both are trying to save money for their incoming child. Although
Husband has a job, his income is still unstable and they are still dependent on
Husband’s parents.
Husband’s father also works at the fish market and has an income of
P200-300 depending on his share; while his mother also stays at home.
No one in the family was able to finish college. Most of them only
reached high school.
The family sleeps at least 8-10 hours every night. They only exercise
when they work. Patient is currently taking Ferrous Sulfate as her iron
supplementation while the others do not take any vitamin supplementation.
They have poor sanitation practices and does not or rarely goes to the
hospital for a medical check-up for any disease.
FAMILY HEALTH PROBLEMS
• Teenage Pregnancy