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Admission/ Final Diagnosis

Admission: Pregnancy, Uterine 29 1/7 wks AOG, Cephalic in presentation for spontaneous
vaginal delivery with RMLE TR, Sedative
Final Diagnosis: Pregnancy, Uterine Delivery, Cephalic Presentation, Preterm Live Birth

Health History and Physical Examination

Demographic
1. Client·s Initials: A.K.A.
2. Gender: Female
3. Age: 20 years old; Birthdate: may 19,1990; Birthplace: Trece Martinez
4. Marital (Civil) Status: Single
5. Nationality: Filipino
6. Religion: Roman Catholic
7. Address and Telephone Number: Lt.71 Brgy Elana Trece Martinez
Cavite; N/a
8. Educational Background: High School Graduate
9. Occupation: Production Operator
10. Usual Source of Medical Care: Hospiital/ Clinic
11. Date of Admission: November 25, 2010 6:14 a.m.

Source of Reliability

The patient was competent to provide information. She was able to speak clearly.
Conscious and coherent, oriented to self, time and place and person. Patient was
comprehensive and reliable, and able to articulate clearly.

C. Reasons for Seeking Care or Chief Complaints

´Masakit ang tyan ko.µ

´May dugo sa pantalone ko.µ
´nahihirapan ako humingaµ

D.History of Present Illness or Present Health

The patient was on normal track to a term birth when the patient started to feeling pains in her
abdominal and pelvic regions. On November 24,2010 around 11:50 p.m. she started feeling a
heaviness in her chest. The patient tried to ignore the pains but the pains persisted through the night
and became unbearable for her to handle. After rubbing her stomach to further try to releive her pains
she nearly collapsed. At that time, she informed her mother that she thought she might be going into
labor, or something must be wrong with the baby. (+) bloody show, (+) Bag of water, uterine 29 1/7
weeks age of gestation, patient was than admitted on November 25, 2010at 6:14 am.

E.Past Medical History or Past Health

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Pediatric/ Childhood: Fever and Colds

Injuries or Accidents: none
Hospitalizations and Operations: Ocober 20 2010, Pregnancy Induced Hypertension
Reproductive History: Age at Menarche: 16 y/o, LMP: May 4, 2010, OB Score: G1P0
1001, Birth Control Methods: No oral contraceptives, abstinence
Immunization:
BCG: /X/ At Birth /X/School Enterance
DPT: / x/1st dose /x /2nd dose /x /3rd dose
OPV: /X/1st dose /X/2nd dose /X/3rd dose
TT: /X/1st dose /X/2nd dose /X/3rd dose /X/4th dose /X/5th
dose
HBV: /X/1st dose /X/2nd dose /X/3rd dose
Others: none
Allergies:
/ / Foods, please specify:none
/ / Drugs or Medications, please specify:none
/ / Chemicals, please specify:none
/ / Other environmental allergens, please specify:none
Medications:
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Patients Age: 20 years old

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Developmental Stage: Love and Affiliation
Developmental Task: Intimacy vs Isolation

The Intimacy vs. Isolation conflict is emphasized around the ages of 20 to 34. At the
start of this stage, identity vs. role confusion is coming to an end, and it still lingers at the
foundation of the stage . Young adults are still eager to lend their id entities with friends. They
want to fit in. Erikson elieves we are sometimes isolated due to intimacy. We are afraid of
rejections such as eing turned down or our partners reaking up with us. We are familiar with
pain, and to some of us, rejection is pa inful; our egos cannot ear the pain. Erikson also
argues that "Intimacy has a counterpart: Distantiation: the readiness to isolate and if
necessary, to destroy those forces and people whose essence seems dangerous to our own,
and whose territory seems to encroach on the extent of one's intimate relations"

Once people have esta lished their identities, they are ready to make long
term
commitments to others. They ecome capa le of forming intimate, reciprocal relationships
and willingly make the sacrific es and compromises that such relationships require. If people
cannot form these intimate relationships ,perhaps ecause of their own needs ,a sense of
isolation may result



 
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