Chief Complaint: “ I feel abdomen cramps and I pee frequently”

Source and setting: Patient reported in an out-patient setting on November 23, 2020 before her
admission.

History of present illness: Patient is 28 years old Filipino female currently in her fourth pregnancy at 38
weeks with an admitting diagnosis of Intrauterine pregnancy, 1 cm dilated. Her last menstual period was
25th of February. The patient reported that she experienced frequent urination and did not experience
fevers, chills, vomitting, nausea or any bowel complaints. She is experiencing lower abdominal and back
pain since 3:00 in the morning until now. The patient denies any alcohol or softdrinks consume since
yesterday that she only ate meat and drank a lot of water. Since onset, her pain did not improve until
this morning. She also adds that the pain is worse with or without any body movements or in any
position. The patient rate 3 out of 10 from the pain scale. The patient also denies any heavy workouts or
exercises.

History of past illness: The patient never had any type of surgeries except a c-section in one of her
pregnancy and she also added that she had an abortion in her first pregnancy. She also denies having
any BCG or anti-cervical immunizations before. The patient have never been in any accidents or injuries
before. She also denies any medication intake like vitamins or iron but she takes medications prescribe
by her doctor. The patient doesn’t have any type of allergies. No known environmental, food or seasonal
allergies. On the patients family history, her living father has diabetes and in her mother side they have
highblood pressure and asthma. On the social history of the patient, she is a business woman. Married
with 3 kids, one son and a twin of girls. The patient drinks alcohol socially but never during her
pregnancians and denies any drug usage or smoking. About her sleeping patterns, the patient sleeps
enough during weekends and she lacks sleep during workdays. Concerning to her sexual practices the
patient was sexually active 12 months ago with her partner and she never used any pill, birth controls or
methods because she thinks it can cause loss of libido.