MORNING REPORT

October 17th 2012

Supervisor : dr. Made
Mahayasa, Sp.OG
Medical Students :
Diah, Rani, Dini F, Indah, Subi
CASES RESUME
NORMAL LABOR

PATHOLOGY
LABOR

1.Rupture Ectopic Pregnancy

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

Patient referred from GP

with gravida, abdominal
pain
and
vomiting.
Patients
admitted
3
month pregnant and has
pregnancy test, result
(+). Patient confessed
abdominal pain, since 4
days ago, Characteristic
of abdominal pain :
intermittent, first in the
lower abdomen, and then
to all abdomen parts.
Patient
confessed
vomiting, blood came out
from her womb (-) and
got a massage from TBA
1.

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

Observe vital sign

and
patient
complaint.
CIE mother to take
a rest.

(-)

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

Observe vital sign

and
patient
complaint.
CIE mother to take
a rest.

01.3
0

07.3
0

7x2cm