Kehamilan Ektopik

Terganggu
William
IDENTITY

• Name : Ny.FA

• Age : 31 yo

• Gender : Female

• Religion : Protestan

• Address : Jl. Melati

Anamnesis

• Main complaint :

• Pain in lower abdominal

• Additional complaints :

• Abdomen feels cramps accompanied by nausea

and vomiting
Current medical state

• Patient 31 years old with G2P1A0 came to emergency room tell that she feels pain in her
abdomen since this evening at around 18.00 pm, pain in abdominal spread from lower to upper
abdominal and lastly in whole abdominal
• This evening she had nausea and vomitting twice
• There is no fever
• BAB and BAK in normal state, no pain,and blood from vaginam and urine (-)
• Last Menstruation at the end of January and only 1 day (usually the patient admits the cycle is 5-
day )
• History of trauma (-)
Physical Examination
• General Condition : Compos mentis / TSS
• Vital Sign : Normal State
-TD : 100/60
- HR : 80
- RR : 21
- Temprature : 36,2c
- Sp02 : 99%
• Eyes : CA +/+ , SI -/- , Pupil ishokor 3mm/3mm
• Thorax : RH-/- , WHZ -/-, Vesikuler +/+
• Abdomen : BU +, Defans muskular +,tenderness + (almost in whole
abdominal ), MANTRELS = 4
• Extremities : Warm and CRT <2s
• USG = full of free fluid in Cavum Douglas
• Example of KET in USG
 History of Pregnancy
• History of pregnancy : G2P1A0
• HPHT :-
• KB : KB (-)
• History of Pregnancy

no kehamilan persali Di tolong Aterm BBL/JK Keadaan Penyulit

nan oleh
1 1 Normal Doctor + - Normal -
2 This
pregnant

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 History of Pregnancy

Menstruation history Wedding History

• Menarche : 14 years old • Marriage : first marriage
• Siklus Haid : 28 day
• Lama Haid : 5 day • Years of marriage : 2 years
• Dismenorrhea : (+)

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 Ginecology

• Inspection : vulva and vagina dbn, Bleeding from vaginam (-),

• VT:
- Vulva and vagina normal, blood (-)
- Portio : Stiff, there is no opening, and feels pain when VT movement to the
right and left (nyeri goyang) (+)

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 Laboratorium Result
15/02/2018
20:54 PM

Pemeriksaan Hasil Nilai Rujukan Satuan

Haemoglobin 10.1 11.5 – 16.5 g/dL
Hematokrit 29.6 36 - 47 %
Leukosit 18.62 5 - 10 103/µL
Trombosit 261 150 – 450 10s/µL
PP Test +

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ASSESMENT
• G2P1A0 with shock hypovolemic ec KET
Theraphy
• IVFD RL 1500ml/24jam
• Inj ranitidine 50mg/8jam
• Inj antrain 1gr/8jam

• Report to dr.Ketut Spog

• Double IV line
• Bolus RL 1000ml
• DC
• HB Serial Cito
• Check PT,APTT

• Report to dr Agus Span

• Transfusion 1 bag of prc
• Check UTD if there is more prc : 1 bag prc left in UTD
• Transfusion 1 more prc (16/2/18)
 Laboratorium Result
15/02/2018
22:58 PM

Pemeriksaan Hasil Nilai Rujukan Satuan

Haemoglobin 8.4 11.5 – 16.5 g/dL
Hematokrit 25 36 - 47 %
Leukosit 16.14 5 - 10 103/µL
Trombosit 206 150 – 450 10s/µL
PP Test +

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 Tanggal/ Catatan Instruksi
Jam
16/2/2018 S : Difficult to evaluate -IVFD : RLD5 100cc/jam while
O : General condition : Moderate pain fasting
Mental State : CM - Ceftriaxone 1g/12 hour
T : 100/70 mmHg - Metronidazole 3x500mg
R : 22 x/mnt - Check HB post op
N : 112 x/mnt - -If HB ≤ 8 pro transfusion PRC
S :36,7 ᵒc till HB ≥ 8
SP02 : 100 % on Ventilator - Gradually mobilitation
Mata : anemis (-), icterus (-) - Others therapy follows dr.agus
Thorax : Cor : BJ I – II regular Span
Pulmo : vesikuler
Abdomen : supel (+), weak sound of bowel (+)
Genitalia : Blood (-), mucus (-), fluor albus (-)
Extermity : warm(+), CRT <2s (+), edema (-)
Otonom : flatus (-), BAB (-)
A : Post op laparotomy exploration +
Salphingektomy sinistra ec ruptur of tuba
 Tanggal/ Catatan Instruksi
Jam
17/2/2018 S : Pain at surgery wound -IVFD : RLD5 100cc/jam while
Flatus (+) fasting
O : General condition : Mild pain,GCS 15 VAS1 - Ceftriaxone 1g/12 hour
Mental State : CM - Metronidazole 3x500mg
T : 110/70 mmHg - Asmef 3x500mg
R : 20 x/mnt - Folamil 1x1 tab
N : 72 x/mnt - Gradually mobilitation
S :36 ᵒc - Others therapy follows dr.agus
Mata : anemis (-), icterus (-) Span
Thorax : Cor : BJ I – II regular - Plan move to nifas room
Pulmo : vesikuler
Abdomen : supel (+), bowel sound (+), surgery
wound in good treatment
Genitalia : Blood (-), mucus (-), fluor albus (-)
Extermity : warm(+), CRT <2s (+), edema (-)
Otonom : flatus (+), BAB (-)
A : Post op laparotomy exploration +
Salphingectomy sinistra ec ruptur of tuba H+1
- Anemia hipomikro HB 10.1 post tranfusion 1
bag of prc and 2 whole blood
 Tanggal/ Catatan Instruksi
Jam
18/2/2018 S : Pain at surgery wound -IVFD : RLD5 100cc/jam while
Flatus (+) BAK (+) via DC fasting
O : General condition : Mild pain,GCS 15 VAS1 - Ceftriaxone 1g/12 hour
Mental State : CM - Metronidazole 3x500mg
T : 90/61 mmHg - Asmef 3x500mg
R : 20 x/mnt - Folamil 1x1 tab
N : 70 x/mnt - Mobilitation
S :36 ᵒc - Diet TKTP
Sp02 : 97% - AFF DC this evening
Mata : anemis (-), icterus (-)
Thorax : Cor : BJ I – II regular
Pulmo : vesikuler
Abdomen : supel (+), bowel sound (+), surgery
wound in good treatment
Genitalia : Blood (-), mucus (-), fluor albus (-)
Extermity : warm(+), CRT <2s (+), edema (-)
Otonom : flatus (+), BAB (-)
A : Post op laparotomy exploration +
Salphingectomy sinistra ec ruptur of tuba H+2
- Anemia hipomikro HB 10.1 post tranfusion 1
bag of prc and 2 whole blood
 Tanggal/ Catatan Instruksi
Jam
19/2/2018 S : Pain at surgery wound -IVFD : RLD5 100cc/jam while
Flatus (+) BAK (+) walking mobilitation (+) fasting
O : General condition : Mild pain,GCS 15 VAS1 - Cefadroxil 2x 500mg
Mental State : CM - Metronidazole 3x500mg
T : 112/78 mmHg - Asmef 3x500mg
R : 20 x/mnt - Folamil 1x1 tab
N : 78 x/mnt - Mobilitation
S :36 ᵒc - Control at 22/2/18
Sp02 : 98%
Mata : anemis (-), icterus (-)
Thorax : Cor : BJ I – II regular
Pulmo : vesikuler
Abdomen : supel (+), bowel sound (+), surgery
wound in good treatment
Genitalia : Blood (-), mucus (-), fluor albus (-)
Extermity : warm(+), CRT <2s (+), edema (-)
Otonom : flatus (+), BAB (+) BAK (+)
A : Post op laparotomy exploration +
Salphingectomy sinistra ec ruptur of tuba H+3
- Anemia hipomikro HB 10.1 post tranfusion 1
bag of prc and 2 whole blood