Professional Documents
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PATHOLOGY
LABOR
Name
: Mrs. A
RM
: 061643
Age
: 23 years old
Address
: Penimbung, Gunung
Sari
Admitted : October 17th 2012,
21.50 WITA
TIME
SUBJECTIVE
17/1
0/20
12
21.1
0
LMP : forget
History of USG : never
History of family planning
: injection 3 months.
Obstetrical History :
1.Male, aterm, TBA, live,
6 y o.
2.Male, aterm, TBA, live,
4 y o.
3.This
OBJECTIVE
General Status :
GC/GCS : weak, E4V5M6
BP : 110/80 mmHg
PR : 90 bpm
RR : 22 bpm
Temp : 36,5oC
Eye : pallor (+/+), icteric
(-/-)
Cor : S1S2 single regular,
murmur (-), gallop (-).
Pulmo : vesicular (+/+),
wheezing (-/-), ronkhi (-/-).
Abdomen :
enlarged
abdomen (+), defense
muscular
(-),
pain
tenderness
(+),
UFH
impalpable.
Extremity : edema (-/-),
warm acral (+/+).
Gynecology Status :
Inspeculo : (-), erosi (-),
livide (-), fluxus (+), active
bleeding (-), fluor (-).
VT
:
(-),
tissue
impalpable, CUAF, slinger
pain (+), APCD normal.
ASSESSMENT
PLANNING
GP3A0L2
with suspect
Ruptured
Ectopic
Pregnancy
Infuse RL
DM consult to
SPV, pro USG.
Advice : brings
the patient to
operation room,
SPV exam, result
: cyto
Laparatomy
Ruptured
Ectopic
Pregnancy
CIE patient and
family.
TIM
E
SUBJECTIVE
Chronologist GH:
17/10/2012
S : Patient 3 month
pregnancy confessed
abdominal pain, vomiting
(+), bleeding (-), history
of massage (+).
O : BP : 110/70 mmHg
PR : 92 bpm
T: 37 c
A: gravida, abdominal pain,
vomiting
P:
Refer to NTB GH
OBJECTIVE
Lab Examination :
HB : 8,5 g/dl
RBC : 2,28 M/L
WBC : 11,91 K/L
PLT : 232 K/L
HCT : 25,7 %
HbSAg : (-)
ASSESSMENT
PLANNING
TIME
SUBJECTIVE
23.0
0
Patient confessed
abdominal pain
most frequently
and very
severely, and
patient confessed
hart to breathe
23.3
0
OBJECTIVE
ASSESSMENT
PLANNING
Prepare laparatomy :
Insert DC
Skin test (-), inject. Ampicillin
2 g/IV.
Laparatomy began
Intraoperatif Result :
of
tuba
pars
Rupture
ampullaris dextra and adhesi
to ovarium dextra
Tuba and ovarium sinistra
normal
Intra-abdominal bleeding
2000 cc, clot 500 cc
SOD
Post Laparatomy :
Transfuse 2 kolf PRC until HB
> 8 gr%
Lab
examination
post
transfuse
Ampicillin 3x1 gr
Observe VS and patient
complaint
TIME
SUBJECTIVE
OBJECTIVE
ASSESTMENT
PLANNING
18/1
0/20
12
Patient confessed
wound pain.
GC : well
BP : 120/80 mmHg
PR : 90 bpm
RR : 20 bpm
T : 36,7oC
UO : 200 cc
Active bleeding : (-)
Operation
wound
good
2 hours post
laparatomy
(-)
GC : well
BP : 120/70 mmHg
PR : 80 bpm
RR : 20 bpm
T : 36,8oC
UO : 100 cc/hours
Active bleeding : (-)
Operation
wound
good
1 day post
laparatomy
01.3
0
07.3
0
7x2cm