Resume of Case September 16th, 2011

Supervisor : dr. Made Mahayase, SpOG MS :Ita, Uyunk, Lili, Atun Phisiology : Phatology:

Identitied
Name : Mrs. F Age : 23 years old MR : 007422 Adressed: Gangga, KLU

Admitted to GH of NTB on September 16th, 2011 at 10.30

Time 10.00 (16/9/ 2011)

Subject Patient reffered from Tanjung GH with abortus imnents . Patient confess abdominal pain (+) since 2 days ago, flak (+) since a month ago, but active bleeding from vaginal since 15/09/2011. History of Asthma (-), DM (-), HT(-). LMP : 12-07-2011 EDD: 19-04-2012 History of family planning : 3 month injection Next family planning : 3 month injection Chronologist : 15-09-2011 08.00 WITA S : patient came to Tanjung GH with Abdominal pain (+) since 2 days ago and flak since a month ago,. O: General condition : well Cons : CM BP : 110/70 mmHg PR : 80 bpm RR : 20 x/minute T : 36,5C VT : (-), bleeding (+), A: abortus iminents P:reffered to NTB GH

Object General status: General condition : well Cons : CM BP : 110/70 mmHg PR : 96 bpm RR : 20 x/minute T : 36,8C Eyes: an (+/+), ict (-/-) Pulmo: ves (+/+), Rh (-/-), Wh (-/-) Cor: S1S2 regular singel, m (-), g (-) Gynecology status : Abdominal palpation: -Abdominal pain palpation (+) -Inspeculo: bleeding from OUE, portio livide (+). VT : CD (-), slinger pain (+), Adnexa pain palpation (+), tissue palpation (-).

Assestment Suspect rupture actopic pregnancy

Planning - Obs. Mother well being -Coass to GP: pro USG Pro laparotomy -Report to supervisor Adv: ACC USG

Time 10.15 (16/9/2011)

P USG result : -Rupture ectopic pregnancy -Ovarium cyst dextra

10.30 (16/9/2011)

Lab. Examination : Hb : 8,4 gr% RBC : 3,85 Lekosit : 11,1 Trombosit : 262 Hematokrit : 26,6%

Report to supervisor : Adv : Laparotomy KIE patient and family Cek DL Injection ampi 2 gr/iv Laparotomy began

12.00

12.15

Intra operation found: -Abortus tuba pars ampularis dextra -Bleeding 500cc -Blood clote 500cc -Ovarium cyst dextra diameter 5cm

Time 13.40 (16/9/2011)

S Anemia (+/+)

O Mother GC : well BP ; 100/70mmHg PR : 88bpm RR : 22 x T : 36,3C UO : 200 cc Active bleeding : Lochea : + Mother GC : well BP ; 100/70mmHg PR : 90 bpm RR : 22 x T : 36C Active bleeding (-), Lochea (+) UO : 500 cc Lab examination : Lab. Examination : Hb :6,6 gr% RBC : 2,40 Lekosit : 7,99 Trombosit : 203 Hematokrit : 0,19 %

A 1 hour post laparotomy

P -Observation patient -Cek DL if 8 gr transfuse PRC till HB 8 gr

14.40 (16/9/2011)

2 hour post laparotomy

Obs vital sign Co to GP Adv : transfuse 3 kolf PRC

Time 07.00

S Wound operation pain (+)

O Mother BP:110/70 mmHg PR: 74 /m RR:20/m T: 36,5 C UO: 500cc/3 hours Vaginal active bleeding (-)

A 1 day post laparotomy

P Obs mother well being