PATIENT CLINICAL RECORD

(Obstetrical Case)

Name: FREYA LEGEND Ward: _____OB________

Age: 31 Sex: Female Civil Status: Married Hospital Number: _OB-26_
Nationality: Filipino______ Religion: Roman Catholic_____ Occupation: ___Registered
Teacher____
Address: ____Brgy. I, Magsingal, Ilocos Sur _______________________________________________
Date and Time Admitted: 02/23/21 – 11:30pm Examined by: ____Dra. Angela
Vale______________
Chief Complaint: ABDOMINAL PAIN AND LOW BACK PAIN
HISTORY OF PRESENT ILLNESS: _The patient states that she felt a sudden pain in her abdomen that
radiates to the lower back when she woke up around 10pm and rated it 10 out of 10. The patient denies
dizziness, fevers or chills._She describes the pain like intense and painful cramps during a menstrual
period. The patient has fatigue. The patient’s feet is edematous.
PAST MEDICAL HISTORY: __Abortion________________________________________

FAMILY HISTORY:
____DM ____HPN ____HEART DISEASE ____CA            ____ASTHMA
____OTHERS: ________

MENSTRUAL HISTORY:
MENARCHE: 11 yrs old Interval: Regular/23 days_ Duration: 5 days Amount: _Normal_
Dysmenorrhea: _____________________ Subsequent Menses: ____ Regular    ____ Irregular

OBSTETRICAL HISTORY
G _3_
T _1_
P _0_
A_1_
L_2_
LMP: 06/1/20 EDC: 03/08/21 AOG:_38weeks and 1 day_

PRENATAL HISTORY:
Check-up: ____Yes ____No       Place of PNCU: ___n/a______Duration: _first trimester_
Abnormal signs and symptoms: ________________n/a___________________
Multivitamins: ___multivatimins and iron supplements_____
Method of Contraception: ___________n/a___________

REVIEW OF SYSTEMS:
Skin ___pallor ___jaundice ___cyanosis ___lesions
Head/neck ___dizziness ___headache ___blurred vision ___nape pain
Chest/ Lungs ___dyspnea ___coughs ___hemoptysis
CVS ___palpitation ___chest pain ___orthopnea ___easy fatigability
Musculoskeletal system ___joint pain ___weakness ___edema

Attending Physician: _____Dra. Angela Vale_______________________