Identity

Name
: Mrs. DA
Age : 44 Years Old
Address
: Ampenan
Admitted on : January, 8th 2013
(00.10 Wita)
Med. Record : 041758

TIME

SUBJECTIVE

08/01/
13

Patient came to NTB GH with

blood came out from her
womb since 19.00 (07-012013). Blood color is fresh
red, abdominal pain(-).
Last menstrual cycle 3
months ago.

00.10

Theres no history of DM, HT,

asthma .
LMP : forgot
EDD : History of ANC : History of USG : 1x.
Result : GS (+) intra
uterine, fetal heart rate
(-)
History of Obstetiric:
I. Male, 3200 g, midwife, 21
years old
II. Female, 2500 g, midwife,
17 years old
III . Abortus
IV . this

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

Eye : an (-/-), ict (-/-)

Thorax : Cor S1 S2 single
regular, murmur (-), gallop
(-). Pulmo ves (+/+), wh
(-/-), rh (-/-)
Abdomen : scar (-), striae
(+), distention (-), UFH 3
fingers above sympisis, local
pain (+).
Extremity : edema (-/-)
Genital :
Active bleeding (+). VT :
(+), APCD normal, mass (-),
slinger pain (-), CUAF.
15.00

Prepare patient to section curet

Blighted ovum

CIE patient and

family.

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

Patient body is weak.

General status

Post curet

GC : weak
GCS : E4V5M6
BP : 130/80
HR : 88
T : 36,8
RR : 20
19.00

Patient body is weak, dizzy (+).

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

1 day post curet

Observation
bleeding
Amoxicillin
3x500 mg.