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CASE RESUME
NORMAL LABOR
PATHOLOGY LABOR
TIME
SUBJECTIVE
08/01/
13
00.10
OBJECTIVE
GC : well
GCS : E4V5M6
BP : 120/70
T : 36,7
HR : 82
RR : 19
General status
Eye : an (-/-), ict (-/-)
Thorax
Cor : S1 S2 single regular,
murmur (-), gallop (-)
Pulmo : ves (+/+), wh (-/-), rh
(-/-)
Abdomen
Inspection : scar (-), striae
(+), distention (-),
Palpation : UFH 3 fingers
above sympisis
Extremity : edema (-/-)
Gynecological status
Inspeculo : livide (+), fluxus (-),
active bleeding (-)
VT : (-), APCD normal, mass
(-), slinger pain (-), CUAF.
ASSESSMENT
PLANNING
AB iminens
Infuse RL 500cc
Observation
bleeding
Observation patient
well being
Pro USG
DM consult to GP
observation at
Melati.
TIME
SUBJECTIVE
OBJECTIVE
ASSESSMENT
PLANNING
Lab Evaluation
HB : 13,6 g/dl
RBC : 4,64 x106/l
HCT : 42,0 %
WBC : 13,12x103/l
PLT : 334 x103/l
HbSAg : (-)
10.00
USG
Blighted ovum
Observation
bleeding
Observation
patient well
being
Blighted ovum
Observation
bleeding
Observation
patient well
being
GS (+) intrauterine
Dx : blighted ovum
09/01/
13
07.30
General status
GC : well
GCS : E4V5M6
BP : 120/80
HR : 88
T : 36,7
RR : 19
Eye : an (-/-), ict (-/-)
Thorax : Cor S1 S2 single
regular, murmur (-), gallop (-).
Pulmo ves (+/+), wh (-/-), rh
(-/-)
Abdomen : scar (-), striae (+),
distention (-), UFH 3 fingers
above sympisis
Extremity : edema (-/-)
TIME
14.45
SUBJECTIVE
Patient confessed abdominal pain
and blood come out from her
womb.
OBJECTIVE
General status
ASSESSMENT
blighted ovum
GC : well
GCS : E4V5M6
BP : 140/80
PLANNING
DM consult to
GP, GP consult
to SPV.
Advice :
section curet.
HR : 80
T : 36,8
RR : 20
Blighted ovum
TIME
17.00
SUBJECTIVE
Patient confessed abdominal pain
and blood come out from her
womb.
OBJECTIVE
ASSESSMENT
General status
PLANNING
section curet
begin. Tissue
and blood
came out
30cc.
GC : GCS : BP : 140/80
HR : 80
T : 36,8
RR : 20
active bleeding (-).
17.10
General status
GC : GCS : BP : 140/80
HR : 84
T : 36,8
RR : 20
active bleeding (-).
Post curet
Tampon aff
after 2 hours.
Observation 2
hours, if patient
condition good
move to
melati.
If active
bleeding (+)
inj. Metergin 1
amp
Amoxicillin
3x500 mg
Prepare for
MOW
tomorrow.
TIME
17.15
SUBJECTIVE
-
OBJECTIVE
General status
ASSESSMENT
Post curet
PLANNING
Tampon
GC : GCS : BP : 130/80
HR : 88
T : 36,8
RR : 20
18.00
General status
Post curet
GC : weak
GCS : E4V5M6
BP : 130/80
HR : 88
T : 36,8
RR : 20
19.00
General status
GC : weak
GCS : E4V5M6
BP : 130/80
HR : 88
T : 36,8
RR : 20
Active bleeding (-)
2 hours post
curet
Aff tampon
Move to melati
TIME
10/01/
13
7.30
SUBJECTIVE
Patient still weak, dizzy (+).
OBJECTIVE
General status
GC : GCS : BP : 130/80
HR : 88
T : 36,8
RR : 20
ASSESSMENT
PLANNING