Biographical Data

Name: Laarnie Timabanan

Age: 23 years old
Birthplace: St. Francis1 Halang, Binan, laguna
Gender: female
Marital status: Single
Occupation: Production operator

Chief Complaint
>Vaginal bleeding
History of PresentIllness
>23 year old female presents with 4 days history of nonstop
vaginal bleeding. Has sensation of heaviness in lower abdomen. Has
noticed some mild dysuria. And 1 day history of ready to discharge.
Current Medications
>Oral contraceptive pills, takes regularly, denies missing pills
Past Illnesses or Past Hospitalizations
>no surgeries, injuries or hospitalizations
Allergies
>no known allergies

Family history:
>Father unknown, Mother has HPN, 3 sisters and 1 brother,in
good health.
Social history:
>Works electronics company, single, lives with her parents.
Drinks 4-6 beers per month, denies smoking or recreational drug
use. Has a boyfriend.
Review of System:
>
Physical examination:
> flat, soft, awake, weak

VS: B/P 90/60, P 76, T 36.8, Weight 170, height 5’1

Skin: No skin lesions or rashes noted; pale skin
Diagnostics Test:
Hematology

Test Result Normal Differential count Result Normal

values values
Hemoglobin 136 140- Segmenters 0.77
170gm/L

Hematocrit 0.40 0.40 – Lymphocytes 0.23 0.25-

0.57 0.35

RBC 4.5 4.5-5.0x10 Blood type “A” Rh

12
/L (+)

Total WBC 9.7 5-10x10

9
/L

UA

Result Norm Resu Normal

al lt values
value
s

Color Light Yellow- Albumi (-)

yellow amber n

Transpar Hazy clear Sugar (-) 1.005-

ency 1.025

Specific 1.010 1.005 WBC 2-3

gravity -
1.025

Ph Alkali RBC 1-2 0-1/hpf

ne

Bacteria Few Few Epithe rare Few

lial

>Transvaginal UTZ- Impression: consider a non viable intrauterine pregnancy

estimated at 8-9 weeks AOG
SOAP NOTES:
Subjective:
• Laarnie Timbanan, 23 years old production operator was complaining of nonstop vaginal
bleeding 5 days and 1 day vaginal discharge. She noticed it when she had an abdominal
pain. She denies that she didn’t take any medication.

Objective:
• B/P 90/60, P 76, T 36.8, Weight 170, height 5’1
• General: has a pale skin and has a fatigued appearance.
• Upon admission she still had a vaginal bleeding, she used 5 pads of napkin in 1 day. She
needs to undergo in a surgery, dilation and curettage. But before undergoing to that
surgery the doctor gave her medication to stop her vaginal bleeding hemostan & sinkabit.
After she undergo to the operation she still look pale and weak. Her vaginal bleeding is
no longer occurred.

Assessment:
• Hormonal imbalance
• Abortion

Plans:
• To reduce or to stop her vaginal bleeding by giving her a medication, ampicillin 100 mg
IVF to treat bacterial infection, and undergoing to an operation because of the
complication that may occur if she didn’t undergo to dilation and curettage operation.
After the surgery the doctor gave her a medication: Analgesic to relive pain.