The patient, a pregnant woman, was admitted to the hospital for hypogastric pain radiating to her lower back accompanied by fetal movement. Upon examination, her vital signs were normal and the fetus was in the cephalic position with intact membranes. During her hospital stay, she was given IV fluids and diagnostic tests. On the first hospital day, she was started on a diet and remained stable. Her final diagnosis was a term pregnancy that resulted in the delivery of a live baby.

1. Provincial Government of Tarlac
Provincial Health Office
Tarlac Provincial Hospital
Landline: (045) 491 8970, Fax: (045) 982 1306
Email: TARLACPROVNICIALHOSPITAL@yahoo.com
DEPARTMENT OF OBSTETRICS AND GYNECOLOGY
CLINICAL ABSTRACT
GENERAL DATA:
The patient is , a G P ( ) from
who was admitted last
HISTORY OF PRESENT ILLNESS:
Few hours PTA ----------------- the patient experienced hypogastric pain radiating to the
lumbosacral area accompanied with good fetal movement hence consult and subsequent admission.
PHYSICAL EXAMINATION:
Conscious, coherent, oriented not in distress
BP: PR: RR: Temp: afebrile
Pink palpebral conjunctivae, anicteric sclera
FH: FHT
IE: cervix dilated, effaced, cephalic, ( ) Bag Of Water, St
COURSE IN THE WARD:
Upon admission the patient was hooked to IVF and diagnostics were requested.
Patient had
On the 1st
HD the patient was started on diet as tolerated and stable
Patient was managed accordingly and the rest of the hospital day was unremarkable.
LABORATORY RESULTS WITH PROCEDURE/S:
See attached
FINAL DIAGNOSIS:
G P ( ) Pregnancy Uterine Delivered term, , Live Baby
APGAR Score: Birthweight: kg, Ballard Score: weeks, for Gestational
Age by
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