Name: Mrs.

s
Age: 36 yo
RM: 539866
Adress: Ampenan, Mataram
Admitted: June, 01 2014
TIME SUBJECTIVE OBJECTIVE ASSESTMENT PLANNING
01/06/
2014
10.00
Patient referred from
Bayangkara RSUD Bayangkara
with Pregnant 6-7 weeks +
history of abortus imimnens,
patient confessed blood leaked
out from her vaginam since 06.00
wita (01/06/2014)
No history of DM, HT, asthma.

LMP: 21/04/2014
EDD: 28/01/2015

History of ANC: -
History of USG: last USG
(31/05/2014) result : KET (-),
free fluid (-)

History of family planning: -
Next family planning: IUD

Obstetrical history:
1. Male , 3200, aterm, SC
2. Female, 3100, aterm ,SC
3. Abortus
4. This


General status:
GC: Mild
Cons: CM/E4V5M6
BP: 80/50 mmHg
PR: 97 bpm
RR: 24 T: 37,5
Eye : palor (-), icteric (-)
Thorax :
Cor : S1S2 single reguler (murmur -
), (gallop -)
Pulmo : vesikuler (+/+), wheezing (-
/-),
Ronkhi (-/-).
Abdomen : scar (-), striae (+), linea
nigra (+), abdominal pain +
Extremity : edema (-/-), warm acral
(+/+)

Gynecological status
Gynecology status :
-Inspeksi : cervix dilatation (-),
vaginal bleeding (-)
- Inspeculo : fluksus (+), fluor (-),
livide (+), tissue(-)
- VT : slinger pain (+), Douglas
cavity not prominent

Susp. Syok sepsis
+ anemia
Obs mother & fetal
well being
DM co to GP co to
spv advice co to
internist , internist
advice : inj certriaxon
Pro ICU
Dopamin 10 mikro
/kgbb


TIME SUBJECTIVE OBJECTIVE ASSESTMENT PLANNING
Chronologist
08.00 ( 01/06/2014)
S: Patient pregnant 5-7 weeks come to
RSUD bayangkara confess lower
abdominal pain,
O: BP: 100/70, PR:80 RR : 16 T 36,
pallor (+),
P: IVFD double line

08.10
Co to GP advice, O2, RL double line , BP:
90/60, RR :74 , T 36,4, PP test +

08.50
A: G4P2A1 6-7 weeks history of abortus
imminens
USG result KET (-), free fluid (-)
Cefotaxim 2 gr/IV
Dulcolax supp II
Infus metronidazole
DC
Lab result : HB 12.8, WBC 26.9,HCT :
4.86 , PLT : 149

Lab:
HB: 7.2
RBC: 3,91 M/dl
HCT: 31,7 %
WBC: 41.45
PLT: 289K/dl
HbSAg: (-)
TIME SUBJECTIVE OBJECTIVE ASSESTMENT PLANNING
12.00 GC: Mild
Cons: CM/E4V5M6
BP: 80/50 mmHg
PR: 97 bpm
RR: 24 T: 37,5

DM co to GP pro USG
and Check HB again,
SPV advice :
Check HB again
12.30

GC: Mild
Cons: CM/E4V5M6
BP: 90/60 mmHg
PR: 97 bpm
RR: 24 T: 36,8

Lab:
HB: 5.0
RBC: 3,91 M/dl
HCT: 31,7 %
WBC: 41.45
PLT: 289K/dl


Susp. Syok sepsis +
severe anemia

DM co to GP pro USG,
GP co to SPV advice :
USG :
13.00





Result of USG : Uterus
normal, free fluid (+),
Suspect KET
TIME SUBJECTIVE OBJECTIVE ASSESTMENT PLANNING
12.00 GC: Mild
Cons: CM/E4V5M6
BP: 80/50 mmHg
PR: 97 bpm
RR: 24 T: 37,5

DM co to GP pro USG
and Check HB again,
SPV advice :
Check HB again
12.30

GC: Mild
Cons: CM/E4V5M6
BP: 90/60 mmHg
PR: 97 bpm
RR: 24 T: 36,8

Lab:
HB: 5.0
RBC: 3,91 M/dl
HCT: 31,7 %
WBC: 41.45
PLT: 289K/dl


Susp. Syok sepsis +
severe anemia

DM co to GP pro USG,
GP co to SPV advice :
USG
13.00





Result of USG : Uterus
normal, free fluid (+),
Suspect KET
SPV advice laparatomy
eksplorasi
TIME SUBJECTIVE OBJECTIVE ASSESTMENT PLANNING
15.30 Laparatomy began,
introperative finding
Stoll cell and blood
2000 cc intraabdomen,
rupture tuba pars
ampularis, tubektomi
dextra and sinistra
16.00



Patient referred to RS
biomedika because ICU
full