DEMOGRAPHIC DATA:

Gina Dayto
Married
38 years old
Birthplace: Negros Occidental
Address: Malabon
Birthday: 03/09/1979
G8P7
CC: Vaginal bleeding with passing of tissue
LMP: Jan. 15, 2017 (13 and 3/7 weeks)
Admission Date: 04/19/2017
Final Diagnosis: Non-induced, Non-septic incomplete abortion

COURSE IN THE WARD:

VS: Stable from 7am-9:00 am
@9:15 onwards - BP: 110/60, Temp: 37.6-38C.

STATEMENT OF THE MOTHER:

4 na diaper ang equivalent ng pagdurugo niya bago siya dalhin sa hospital
Yung balakang niya sumakit ng sobra at may hilab sa tiyan niya noong madaling araw
(04/18/2017)
Kapitbahay yung nagsugod sa kanya sa hospital kasi nasa trabaho si mister
Blood type: O+
NPO since 12 pm (04/18/2017)
6 pm ginawa yung procedure which is D&C

OTHER INFORMATIONS:
IV:
April 19 (1) D5LR 20gtts/min
(2) DNSS 14gtts/min
(3) DNSS 14 gtts/min (Nagstart ng 6am and matatapos ng 6pm that day din)
HEMATOLOGY:
DATA PATIENT'S VALUE NORMAL VALUE
Hemoglobin 74 (LOW) 110-150
Hematocrit 0.223 (LOW) 0.37-0.45
WBC 13.5 (HIGH) 4.6-10
RBC 2.96(LOW) 4.0-5.5
MCV 75.4 80.9-99.9
MCH 25.0 27-31
PLATELET 323 150-400
MEDICATION:
Ampicillin
 Paracetamol

1U PRBC 200cc.
@10 am, tanggal ng RBC kasi ubos na.