OB Ward Work Informant: Patient Reliability: 85% I. General Data: K.M. a 22 year old female II.

I. Chief Complaint: Hypogastric Pain III. History of Present Illness: Four Days prior to admission, patient suddenly felt hypogastric pain, o sharp contracting pain, o radiating to lumbar area o severity of 6/10, o lasting about less than 1 minute but unrecalled interval. o no an aggravating factor and no associated bleeding. o gently massage her abdomen, including her back which offered relief. o No medications taken or consult done. Three days prior to admission, there is still the persistence of hypogastric pain o but was now nonradiating. o aggravated by prolonged sitting and urination. o no bleeding or vaginal discharge noted. No consult done. One day prior to admission, hypogastric pain, o now with a severity of 7/10. o No other associated signs and symptoms like bleeding or vaginal discharge. Few hours prior to admission, condition did not improve, which prompted the patient to seek consult. Upon consultation the patient was advised to go under CS. Hence, admitted in R1MC on October 18, 2013 at around 11am. IV. Menstrual History Menarche was at 11 years old, lasting about 10 days, consumed 2 pads per day, and no dysmenorrhea associated. She has regular menstrual cycle of 28 days, duration of 4 days, and uses 2 pads per day. No dysmenorrhea reported. LMP: January 22, 2013

PMP: December 24, 2012 V. Obstetric History G2P1 (1-0-0-1); AOG = 38 weeks; EDC = October 29, 2013 G1 Nov 18, 2010 term boy CS 2.5kg - R1MC hospital delivered by an obstetrician of unrecalled named no complications G2 present pregnancy AOG 38 weeks 7x during her 3rd trimester, given multivitamins and FeSO4 with 1 dose of tetanus vaccine. No maternal illness reported. VI. Contraceptive History Withdrawal was the only contraceptive method used by the patient and her spouse. VII. Sexual History Patients first sexual intercourse was at 19 years old. She had only 1 husband. She usually has 23 times per week of sexual intercourse. Her last intercourse was on August 2013. No dyspareunia reported. VIII. Past Medical History No other previous illnesses or hospitalizations reported. Patient has no known allergies to food and drugs. IX. Surgical History November 18, 2010 CS in R1MC X. Family History Patients father-side has a history of giving birth to a twin (2nd cousin) and a heredofamilial disease of diabetes mellitus and hypertension. No other heredofamilial diseases such as CA, RA, asthma and TB. XI. Social History Patient is a housewife and a highschool graduate. She is a non-smoker, and non-alcoholic drinker but a passive smoker.

XII. Review of Systems:

General Survey (-) wt. Gain (-) chills Skin (-) jaundice (-) sweats (-) fever (-) hematoma (+) fatigue (-) body weakness (-) sores

(-) pruritus (-) pallor (-) lesions (-) rashes (-) signs of dermatosis or bleeding Head & Neck (-) nodules or hematoma (-)Headache (-) asymmetry (-) diplopia (-) itchiness (-) blurring of vision (-) hearing loss (-) infection (-) dryness (-) pain

(-) cyanosis (-) pressure urticaria (-) abnormal hair growth or pigmentation (-) swelling (-) mass (-) dizziness

(-) stiffness (-) trauma

Eyes

(-) infection (-) icteric slera (-) corrective lenses (-) redness (-) pain (-) discharges (-) bleeding (-) sneezing (-) hoarseness (-) dysphagia (-) lumps (-) bleeding

(-) pain

(-)glaucoma

Ears

(-) vertigo (-) discharges (-) obstruction (-) pain (-) dryness (-) pain

Nose

Mouth & Throat

(-) soreness (-) gum bleeding (-) discharges (-) infection

Breasts

Respiratory

(-) cough (-) dyspnea (-) pain (-) hemoptysis (-) history of exposure to respiratory hazards (-) palpitations (-) orthopnea (+) hypogastric pain (-) dysuria (-) incontinence (-) vaginal bleeding (-) hematoma (-) bruising (-) angina (-) edema (-) anorexia (-) hematuria (-) pain (-)lesions (-) pallor (-) transfusion

(-) cyanosis (-) wheezing

Cardiac

(-) chest pain

GIT/Abdomen Genito-Urinary

(-) vomiting

(-) constipation

(-) nocturia

Genitals Hematological

(-) bleeding

XII. Physical Exam

General Survey: The patient is conscious, alert, coherent, not in cardiorespiratory distress and ambulatory. Vital signs: BP = 110/70mmhg, PR = 68 /min, RR = 19/min, Temp. = 36.5 c.

Skin: No pallor, no lesions, good skin turgor, pink nail beds, cold and clammy extremities. Head: Evenly distributed hair, no lesions. Eyes: Pink palpebral conjunctivae, anicteric sclera Nose: no deformities, no nasal discharges Ear: Symmetrical, no deformities, no discharge Mouth and throat: Moist lips, no lesions on buccal mucosa, tongue mobile and at midline. Neck: Thyroid gland not enlarged, no cervical lymphadenopathy. Chest/Lungs: Symmetrical chest expansion, normal tactile fremitus, vesicular breath sounds on both lung fields, no rales, no wheezes, no crackles. Heart: Adynamic precordium, apex beat at the 5th intercostals space left midclavicular line, at normal rate and regular rhythm, no murmurs. Abdomen: globular in shape, presence of linea negra and with previous LTCS scar, fundic height is 32cm, fetal heart tone is noted with 140 bpm, visible contraction LEOPOLDS MANEUVER LM 1 soft, nonballotable LM 2 fetal back palpated on the right, extremities on the left LM 3 the head of the baby is unengaged LM 4 - cephalic flexed presentation, vertex presentation Internal Examination: Cervix is 3cm dilated, beginning effacement, 40% effaced at -3 station, with minimal bleeding. Extremities: no deformities, no clubbing of fingers, no edema Diagnosis: G2P1 (1001), Pregnant Uterine 38 weeks AOG, Cephalic Presentation in Active Labor, t/c UTI Basis: abdominal pain (+) Uterine contraction Cervical dilatation (3cm) Presence of fetal heart tone (140 bpm)