Name

Age
Adress
MR No
Date

: Afrida Yeni
: 22 yo
: Ganting No 84
: 28 9452
: October 18th 2002

Anamnesis
A 22 Years old patient was admitted to the Delivery Room of Dr. M. Djamil Central
General Hospital on October 18th at 01 05 with chief complain pain all regio of the
abdomen
Present Illness History :

Pain all regio of abdomen since 9 hours ago.

Escaped blood from vagina was absent , fever was absent, fluor was absent
History of trauma was absent
The patient that she was pregnant 1 month ago , examine at puskesmas.
The patien was maried 1 year ago
Her husband work as nongoverment employe
Menstruation History : menarche at 14 years old, regular cycle, every 28 days
which last for 5 to 7 days each cycle with the amount of 2-3 times pad change
/day menstrual pain was present.

Previous illness history

No importance
Family illness history
No importance
Marriage history : Once at 2001
History of pregnancy/Abortion/Delivery : 1/0/0
I Present
Contraception history : none
Immunization history : none
Physical Examination
General appearance
Consciousnes
Blood pressure
Pulse Rate
Respiration rate
Temperature

: Moderate
: Fully conscious and cooperative
: 80/60 mmHg
: 96x/m
: 24x/m
: 37 C

Eyes
Neck
Chest
Abdoment
Genitalia
Extremity

: Conjunctiva anemic , Sclera not icteric

: JVP 5-2 cm H2O , Tyroid not enlarge
: H/L Normal
: GR
: GR
: Edema -/- , Physiological Reflex +/+ , Pathological Reflex -/-

Gynecologic Record
Face
Breast
Abdomen
Inspection
Palpation
Percusion

: The pregnancy sign was (+)

: The pregnancy sign was (+)
:
: Sligthly Enlarged and distended
Tight, venectation (-)
: Muscular defense (+), Presure pain (+),
Release pain (+)
: Shifting dullness cant be evaluated

Auscultation : peristaltic sound (+) decreased

Genitalia
I

:
:Vulva/Urethra normal

Inspeculo
Vagina

:
: Fluxus (+) small amount dark red, Flour (-) Laceration (-), Tumor (-),
Chadwick sign (+)

Portio

: NP, Size equal to and adult foot toe, posterior,fluxus (+) small,amount
Dark red Flour (-) Laceration (-), Tumor (-)
OUE closed

Bimanual/ VT : Vagina
Portio
CUT
AP
CD
RT

: tumor (-)
: MP Size equal to and adult foot toe, posterior, tumor (-)
OUE Closed, shaky pain (+)
: cant be evaluated
: cant be evaluated
: Pressure pain (+), protruded

: Anus normal, sphincter in good condition, mucose smooth, ampular empty,

Tumor (-)
Laboratory
Hb : 6,2 gr %
Leukocyte
: 26100
CT
: 430
BT
: 230
Trombocyte : 266. 000
Plano test : (+)
WD/ Acute abdomen ec disturbing ectopic pregnancy + graves anemia
Attitude

Wards pre op
Prepared Laparotomy
Prepared blood 1500 cc
Controle VS, PPV
Consult Operation Room, Anastesi
Plan
Laparotomy
Laparotomy begin at 04 55 am
Laparotomy was performed.
After the peritoneum was opened there was blood and blood clot filled the abdomen
cavity, Evacuated blood from it 1500 cc, Exploration was performed, Uterus as big as
duck egg.
Left Tuba and ovarian shape and size was normal
Found ruptured at Right Tuba pars isthmica
Impresion
Plan

: Ruptured of right tuba pars Isthmica

: Right Salpingectomy

Diagnosed:
Post Right Salpingectomy on indication Rupture right tuba pars isthmica