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Name : Mrs. H RM : 040172

Age : 35 years old Address : Tanjung, KLU Admitted : June 4 th 2012

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TIME SUBJECTIVE OBJECTIVE ASSESSMENT PLANNING

04/06/2012

10.00

Patient came to gynecologypoliclinic NTB GH with bloodcome out from her womb since1 month ago, and lowerabdominal pain since 2 weeks

ago but patient feel very severepain at 23.00 (03-06-2012).Characteristic of blood: blackcolor and clotty.Characteristic of abdominalpain: intermittent

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

Obstetrical History :

1. Female, 3300 gram, aterm,TBA, live, 18 years old.2. Abortus Mola3. Abortion4. Female, 3300 gram, aterm,

PHC, midwife, live, 6 yearsold.

5. This

General Status :GC/GCS : middle, E4V5M6BP : 120/80 mmHgPR : 88 bpmRR : 20 bpm

Temp : 36,4o

C

Eye : pallor +/+, icteric -/-Cor : S1S2 single regular, murmur(-), gallop (-).Pulmo : vesicular (+/+), wheezing(-/-), ronkhi (-/-).Abdomen : enlarged abdomen(+), defense muscular (-), UFH(+) impalpable.Extremity : edema (-/-), warmacral (+/+).

Gynecology Status :Inspeculo : (-), livid (+), fluxus

(+).VT : (-), cavum uteri anteflexi,APCD normal, slinger pain (+),mass (-).

G5P2A2L2 10-11weeks with

Ruptured EctopicPregnancy

Infuse RL Consult to SPV,

advice : preparelaparatomy

CIE patient and

family Inj. Ampicillin 1gram IV (skin test -)

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TIME SUBJECTIVE OBJECTIVE ASSESSMENT PLANNING

Urine pregnancy test : (+)

USG abdomen :- Uterus : ante flexion, normalsize.

- GS extra uterine, + 1,5 cm- Free fluid in cavum peritoneal

(+)- Diagnosis : ruptured ectopic

pregnancy

Lab Examination :HB : 7,0 3 g/dlRBC : 2,64 M/LWBC : 7,24 K/LPLT : 267 K/LHCT : 24,6 %HbSAg : (-)

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TIME SUBJECTIVE OBJECTIVE ASSESSMENT PLANNING

12.00 Laparatomy began : Salpingectomy Intraoperatif Result :

Rupture of tuba pars ampullarissinistra.Hydrosalpinx dextraIntra-abdominal bleeding, Stolsel+ 1500 cc.

Post Laparatomy :Laboratory examination post

operatifWhole blood transfusionInj. Ampicillin 1 gram/6 hoursObserve vital sign and patientcomplaint

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TIME SUBJECTIVE OBJECTIVE ASSESTMENT PLANNING

04/06/2012

15.00

Patient confessed dizzinessand wound pain.

GC : wellBP : 110/70 mmHgPR :96 bpmRR : 24 bpmT : 36,4oCUO : 125 cc/hoursActive bleeding : (-)Operation wound good

2 hours postlaparatomy

Observe vital sign andpatient complaint.

CIE mother to take arest.

05/06/2012

07.00

Patient confessed woundpain

GC : wellBP : 110/70 mmHgPR :96 bpmRR : 24 bpmT : 36,4oCUO : 125 cc/hoursActive bleeding : (-)Operation wound good

1 day post laparatomy Observe vital sign andpatient complaint.

CIE mother to take arest.