Name : Mrs.

H
RM : 040172
Age : 35 years old
Address : Tanjung, KLU
Admitted : June 4
th
2012
TIME SUBJECTIVE OBJECTIVE ASSESSMENT PLANNING
04/0
6/20
12

10.00
Patient came to gynecology
policlinic NTB GH with blood
come out from her womb since
1 month ago, and lower
abdominal pain since 2 weeks
ago but patient feel very severe
pain at 23.00 (03-06-2012).
Characteristic of blood: black
color and clotty.
Characteristic of abdominal
pain: intermittent

LMP : 17/03/2012
Menarche : 15 years old
Menstrual period : 28 days
History of USG : -
History of family planning :
injection 3 months

Obstetrical History :
1. Female, 3300 gram, aterm,
TBA, live, 18 years old.
2. Abortus Mola
3. Abortion
4. Female, 3300 gram, aterm,
PHC, midwife, live, 6 years
old.
5. This
General Status :
GC/GCS : middle, E4V5M6
BP : 120/80 mmHg
PR : 88 bpm
RR : 20 bpm
Temp : 36,4
o
C

Eye : pallor +/+, icteric -/-
Cor : S
1
S
2
single regular, murmur
(-), gallop (-).
Pulmo : vesicular (+/+), wheezing
(-/-), ronkhi (-/-).
Abdomen : enlarged abdomen
(+), defense muscular (-), UFH
(+) impalpable.
Extremity : edema (-/-), warm
acral (+/+).

Gynecology Status :
Inspeculo : (-), livid (+), fluxus
(+).
VT : (-), cavum uteri anteflexi,
APCD normal, slinger pain (+),
mass (-).
G5P2A2L2 10-11
weeks with
Ruptured Ectopic
Pregnancy
Infuse RL
Consult to SPV,
advice : prepare
laparatomy
CIE patient and
family
Inj. Ampicillin 1
gram IV (skin test -)


TIME SUBJECTIVE OBJECTIVE ASSESSMENT PLANNING


Urine pregnancy test : (+)

USG abdomen :
- Uterus : ante flexion, normal
size.
- GS extra uterine, + 1,5 cm
- Free fluid in cavum peritoneal
(+)
- Diagnosis : ruptured ectopic
pregnancy

Lab Examination :
HB : 7,0 3 g/dl
RBC : 2,64 M/L
WBC : 7,24 K/L
PLT : 267 K/L
HCT : 24,6 %
HbSAg : (-)


TIME SUBJECTIVE OBJECTIVE ASSESSMENT PLANNING
12.00 Laparatomy began : Salpingectomy
Intraoperatif Result :
Rupture of tuba pars ampullaris
sinistra.
Hydrosalpinx dextra
Intra-abdominal bleeding, Stolsel
+ 1500 cc.
Post Laparatomy :
Laboratory examination post
operatif
Whole blood transfusion
Inj. Ampicillin 1 gram/6 hours
Observe vital sign and patient
complaint

TIME SUBJECTIVE OBJECTIVE ASSESTMENT PLANNING
04/06
/2012

15.00
Patient confessed dizziness
and wound pain.
GC : well
BP : 110/70 mmHg
PR :96 bpm
RR : 24 bpm
T : 36,4
o
C
UO : 125 cc/hours
Active bleeding : (-)
Operation wound good
2 hours post
laparatomy






Observe vital sign and
patient complaint.
CIE mother to take a
rest.


05/06
/2012

07.00
Patient confessed wound
pain
GC : well
BP : 110/70 mmHg
PR :96 bpm
RR : 24 bpm
T : 36,4
o
C
UO : 125 cc/hours
Active bleeding : (-)
Operation wound good
1 day post laparatomy





Observe vital sign and
patient complaint.
CIE mother to take a
rest.