Pain assessment:

Subjective (reports):

Primary focus: Location: Hypogastric region / women abdomen Intensity:6

Quality: aching & bloated

Radiation: none Duration: persistent pain Frequency: Sudden onset

Precipitating factors:3-5 days without Bowel Movement

Relieving factors: Bowel movement

Associated symptoms: Abdominal Bloated

Effect on daily activities: Physical Activities Enjoyment of life: no enjoyment of life unless the
symptoms is treated

Additional pain focus or describe: none

Medications: Before: Ferrous sulfate/ Amino acid/ Calcium After: Laxative

Herbals: none

Objective (exhibits):

Facial grimacing: Moderate pain scale of 6 Guarding affected area: abdominal guarding noted

Emotional response: restlessness Narrowed focus: abdomen

Vital sign changes (acute pain): Temperature:36.8-degree Celsius B.P:120/80 normal: 110/70

Pulse: 80bpm Respirations: 16 cpm

Present pregnancy:

Chief complain:

Abdominal Pain

Danger signals:

Did not have a bowel movement in 4 days

Estimate date of delivery:

Last menstrual period: June 25, 2020

 Date of delivery: March 31, 2021

Last OB-GYNE check-up:

 Is patient taking medication? Yes No□

 Any allergies to medication? None.
 Traveled outside the country recently for the past year? Yes No□
 Any family health history? Please indicate: Hypertension and Diabetes Mellitus

MEDICAL HISTORY

Checklist:

Do you have, or have you had, any

Y N

Rheumatic Fever _  Abnormal healing _ 

Highblood Pressure _  Bleeding tendency _ 
Low blood pressure _  Jaundice/ Liver disease _ 
Chest pain _  Gallbladder trouble _ 
Heart attack/s _  Low blood sugar _ 
Heart Surgery _  On dialysis _ 
Pneumonia/Bronchitis/Chronic cough _  Sexually transmitted disease _ 
Trouble climbing 1-2 flights of stairs _  Contagious disease _ 
Anemia _  Swollen ankles _ 
Asthma  _ Arthritis _ 
Mental health problems _  Osteoporosis/ Osteopenia _ 
Respiratory porblems _  On a diet _ 
history of drug abuse _  Contact lenses  _
history of alcohol abuse _ 

Pre pregnant weight

Exposure to any illness? None

Cardiovascular disease None

History of thrombophlebitis/PE/DVT? None

History of hypertension of renal disease? None

History of Hepatitis, Thyroid disease, Seizures, Urinary tract infections, or Diabetes? Urinary tract
infection

History of Depression/ Mental illness? None

Screening for Domestic Violence None

Details:

Medication/s: vitamins

Operation/s: None

Allergies: seafoods

TB symptom screen: pos□ neg Misuse of herbal medicine_

Tobacco □ Alcohol  Substances □ Misuse of OTC drugs □

Examination

BP / mmHg: 120/70 Urine: negative

Height: 165 cm Weight: 55kg

BMI: 20.8 (Normal)

Invstigations

Syphilis Test: Pos □ Neg 

HIV: Pos □ Neg 