PATIENT’S HEALTH HISTORY

BIOGRAPHICAL DATA
▪ NAME: C. A.
▪ ADDRESS: TACLOBAN CITY
▪ ETHNICITY: WARAY-WARAY
▪ AGE: 25 YRS. OLD
▪ DATE OF BIRTH: JUNE 12, 1994
▪ SEX: FEMALE
▪ CIVIL STATUS: MARRIED
▪ OCCUPATION: PRIVATE EMPLOYEE
▪ ORDINAL POSITION: SECOND

SOURCE OF INFORMATION: PATIENT

OB HISTORY
▪ DELIVERY HISTORY: Gravida 1
▪ LMP: 12/ 01/ 2018
▪ EDC: 10/7/19
▪ AOG: 36 weeks
▪ MENARCHE: 17 yrs. Old
▪ PRENATAL VISIT: 3 visits (EVRMC)
▪ TT STATUS: (patient’s can’t recall)
▪ FALSE LABOR: 2:00 AM
▪ TRUE LABOR: 6:00 AM
▪ ACTIVE LABOR: 4 CM (2:18 PM)
CHIEF COMPLAINT:
▪ Sudden gush of water in the vagina (PROM)
▪ Intolerable abdominal pain

HISTORY OF PRESENT ILLNESS:

▪ Four hours prior to admission, the patient had an abdominal pain at 2:00 AM and
had a sudden gush of water in the vagina, so she decided to go to Eastern
Visayas Regional Medical Center. Upon assessment, she had a lower back pain
at 6:00 am and diagnosed with premature rupture of membrane (PROM), the
patient was advised for admission. She was admitted last September 12, 2019 at
6:00 o’clock in the morning.

PAST HEALTH HISTORY:

▪ CHILDHOOD & INFECTIOUS DSES.: NONE

▪ IMMUNIZATIONS: COMPLETE
▪ ALLERGIES: NONE
▪ MEDICATIONS TAKEN: NONE
▪ MAJOR SURGERIES &PREVIOUS HOSP.: NONE
▪ INJURIES: NONE
▪ FAMILY HISTORY: NONE
▪ SEXUAL HISTORY: 20 yrs. Old (started to have sex)

PHYSICAL EXAMINATION
VITAL SIGNS
▪ TEMPERATURE: 36.2°C
▪ PULSE RATE: 70 bpm
▪ RESPIRATORY RATE: 22 cpm
▪ BLOOD PRESSURE: 130/90 mmHg
▪ SKIN: Fair skin color, no rashes and lesions and no edema observed.
▪ HEAD: No tenderness or deformity, no rashes and lesions observed.
▪ EARS: No drainage observed
▪ NOSE: No swelling and redness, no drainage or deformity noted.
▪ EYES: No lesions, deformities or asymmetry
▪ NECK: Symmetrical, no scars or lesions
▪ CHEST & LUNGS: Chest is symmetrical, RR- 22 cpm normal rate without
experiencing dyspnea.
▪ CARDIOVASCULAR & PERIPHERAL VASCULAR: PR- 70 normal; BP- 130/90
mmHg; No cyanosis of upper and lower extremities; No clubbing of nails.
▪ ABDOMEN: Presence of striae gravidarum and linea negra.
 NARRATIVE FORM
BIOGRAPHICAL DATA:
Mrs. C.A. a 25-yr. old was born on June 12, 1994 and currently residing in Leyte,
and her ethnicity is waray-waray. She is a private employee and married to Mr. J.C.A.
OB HISTORY
She is 36 weeks pregnant with gravida one (1). Her last menstrual period was
December 01, 2018 and expected date of delivery is on October 07, 2019. She had her
first menstrual period when she was 17 yrs. Old. She had her 3 prenatal visits in EVRMC.
Her false labor started at exactly 2:00 am, while her true labor started at 6:00 am and it
was happened that her active labor began at 2:18 pm on the 12 th day of September 2019.
CHIEF COMPLAINT
She complaint about her sudden gush of water in the vagina (PROM). And she
had an intermittent abdominal pain.
HISTORY OF PRESENT ILLNESS:
Four hours prior to admission, the patient had an intermittent abdominal pain at
2:00 AM and had a sudden gush of water in the vagina, so she decided to go to Eastern
Visayas Regional Medical Center. Upon assessment, she had a lower back pain at 6:00
am and diagnosed with premature rupture of membrane (PROM), the patient was advised
for admission. She was admitted last September 12, 2019 at 6:00 o’clock in the morning.
PAST HEALTH HISTORY:
She is fully immunized when she was a child. And she had no past health histories
such as childhood and infectious disease, allergies, medications taken and major
surgeries and previous hospitalizations. And she had no recall about her family history.
She had her first sex when she was 20 yrs. Old.
PHYSICAL EXAMINATION
Mrs. CA has no abnormal findings in her Physical examination. She was in fair
skin color with no lesions and rashes, she wasn’t pale and dry and no edema observed;
no tenderness or deformity in her head, scalps are not dry nor sparse hair; no drainage
observed in her ears; no swelling and redness of the nose; no lesions, deformities or
asymmetry in the eyes; her neck is symmetrical with no lesions or scars; Her chest is
symmetrical with a RR-22 cpm which is normal without experiencing dyspnea; PR- 70
normal, BP-130/90 mmHg; No cyanosis of upper and lower extremities and no clubbing
of nails; Presence of striae gravidarum and linea negra and not inverted nipples. She
has a dark areola.
 UNIVERSITY OF THE PHILIPPINES MANILA-
SCHOOL OF HEALTH SCIENCES
PALO, LEYTE

CLIENT CASE
STUDY

PREPARED BY:
ABIGAIL E. BALBUENA DM40TH

SUBMITTED TO:
MR. BEN DE PAZ, RM, RN, MAN