III.

HEALTH ASSESSMENT
A. HEALTH HISTORY
A.1 HISTORY OF PRESENT ILLNESS
1 hour (PTA) Prior to Admission patient noted irregular
contractions 3 in 15 minutes, 20 sec. in duration. Patient cleared that she
had onset hypogastric pain score of 5/10, patient directly brought to this
institution, upon admission IE was due and shared 7-8cm cervical
dilatation, (PTA) prior to admission patient is persistent of pain, by the
pain score of 9/10.
She was admitted at Cebu Puericulture Center and Maternity
House Incorporated by 11:00 pm. Patient is awake, conscious and
cooperative with vital signs taking: Blood pressure is 100/70 mmHg,
body temperature is at 36.8C, respiratory rate at 16 cycles per minute,
and pulse rate is at 80 beats per minute.
A.2 REASON FOR SEEKING CONSULTATION
Patient experiences labor pain.
A.3 PAST HEALTH HISTORY
Patient is non-hypertensive nor diabetic; has no cardiovascular
disease, no previous hospitalizations, has not undergone any operations yet.;
Patient is non-smoker nor alcoholic drinker, patient does not have any food or
drug allergies. Patient had her menarche at the age of 12, subsequent menses are
of regular interval (5-7 days). She consumes about 2 pads per day and is

moderately soaked. Furthermore, both parents were known for heredo-familial

diseases: Diabetes Mellitus, Stroke related to Hypertension, and Asthma.