Postpartum Case Plan

[gemini61]

I am at a loss in starting my case plan. I was assigned to a post natal 42 year old woman who delivered on full term lady partslly with episiotomy. She was rushed to the hospital due to abdominal pain due to contraction occurring at close intervals. Diabetes runs in her family and has a history of anemia. I was asked to observe for 1 day and has a very limited information of the patient. She is suffering from constipation and taking Colace for stool softening. I need help on History of Present Illness. What do I have to include in the HPI? I do not have a complete list of medications in her MAR. What diagnosis should I include? Help!