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Reported:
1. Post Laparatomy d/t Advanced Abdominal Pregnancy + PD6 +
Anemia
No
1
Income
Outcome
Therapy :
Th/ IVFD RL 20 gtt/i
Diagnose:
-Inj. Ceftriaxon 1 g/12 hr
Post Laparatomy d/t Advanced -Inj. Gentamycine 80 mg/8 hours
Abdominal Pregnancy + PD6 + -Drip Metronidazole 500 mg/8 hr
Anemia
-Inj. Ranitidine 50 mg/12 hr
-Inj. Ketorolac 30 mg/8 hr
Recent condition:
-Tab PCT 500 mg/ 8 hr
Fully alert, BP: 120/70 mmHg,
HR: 86 x/I, RR: 20 x/I, T: 36,8 C
Planning :
14/12/2015
Hb/Leu/Trom:
9.9/26.600/325.000
HCG at 12.30 pm : 36150,6
mIU/mL
PATIENT 1
History of Illness
: Asthma (-), DM (-), Hypertension
(-)
History of pregnancy:
Girl, aterm, 3000 gram, VSD, midwife, home, 12 years, healthy
Boy, aterm, 4200 gram, VSD, midwife, home, 4 years, healthy
Girl, aterm, 3000 gram, C-section, SpOG, hospital d/t advanced
abdominal pregnancy, 3 days, healthy
Status Presens
Sens
BP
HR
RR
Temp
: CM
: 110/70 mmHg
: 100 x/i
: 20 x/i
: 38,70C
Obstetrical state
Abdomen
FH
Vaginal Bleeding
Operation wound
Micturition
Defecation
Anemic
Icteric
Cyanotic
Dyspnoe
Oedem
:
:
:
:
:
(+)
(-)
(-)
(-)
(-)
Hasil Lab
Hb
: 5.5 gr/dl
Leukocyte
: 22.460/mm3
Hematocrit
N: 12-14/gr/dl
N:4000-11000/uL
: 16.8 %
N: 36,0-42,0/%
Trombocyte
: 193.000 /mm3
N: 150.000-400.000/Ul
aPTT
: 43.6
C= 33,0
PT
: 16.0
C= 13,7
INR
: 1,40
SGOT
: 10
N : 0 40 U/L
SGPT
: 10
N : 0 - 40 U/L
Ureum
: 11
N : < 50 mg/dl
Creatinine
: 0,66
N : 0.5-0.9 mg/dl
: 108
N :<140 mg/dL
Natrium
: 135
N : 135-155 mEq/L
Klorida
: 119
N : 96-106 mEq/L
Kalium
: 3,4
N : 3,6-5-5 mEq/L
USG TAS
USG TAS
Bladder filled
Placental in cavum abdominal
Free Fluid (-)
Abdominal pain
Presens state
Sens
: Compos Mentis
TD
: 110/70 mmHg
HR
: 86 x/i
RR
: 20 x/i
T
: 36,5C
Obstetrical state
Abdomen :soepel, peristaltic in normal limit
FH : difficutl to assess
Vaginal bleeding (-), lochia rubra (+)
Operation wound : covered by gauze, surgical wound moist
Micturation : (+) via cathether, uop 50 cc hours
Defecation : (-), flatus (+)
Therapy
IVFD RL 20 gtt/i
- Inj. Ceftriaxon 1 g/12 hr
- Inj. Gentamycin 80 mg/8 hr
- Drip. Metronidazole 500 mg/8 hr
- Inj. Ranitidine 50 mg/12 hr
- Inj. Ketorolac 30 mg/8 hr
- Tab PCT 500 3x1
Transfusion 4 bag PRC
HCG quantitative
Abdominal pain
Presens state
Sens
: Compos Mentis
TD
: 140/90 mmHg
HR
: 88 x/i
RR
: 24x/i
T
: 36,7C
Obstetrical state
Abdomen :soepel, peristaltic in normal limit
FH : difficutl to assess
Vaginal bleeding (-), lochia rubra (+)
Operation wound : covered by gauze, surgical wound moist
Micturation : (+) via cathether, uop 60 cc hours
Defecation : (-), flatus (+)
Therapy
IVFD RL 20 gtt/i
- Inj. Ceftriaxon 1 g/12 hr
- Inj. Gentamycin 80 mg/8 hr
- Drip. Metronidazole 500 mg/8 hr
- Inj. Ranitidine 50 mg/12 hr
- Inj. Ketorolac 30 mg/8 hr
- Tab PCT 500 3x1
- HCG quantitative (result : HCG : 36150,6)
-Post trasnfusion Hb 8,5 g/dL Report to spv. Dr. Riza H. Nst SpOG transfusion 2 bag PRC
Hasil Lab
Hb
: 9.9 gr/dl
Leukocyte
: 36.012/mm3
Hematocrit
N: 12-14/gr/dl
: 16.8 %
Trombocyte
: 325.000 /mm3
LED
: 50 mm/jam
N:4000-11000/uL
N: 36,0-42,0/%
N: 150.000-400.000/Ul
Abdominal pain
Presens state
Sens
: Compos Mentis
TD
: 110/70 mmHg
HR
: 86 x/i
RR
: 20 x/i
T
: 37,5C
Obstetrical state
Abdomen :soepel, peristaltic in normal limit
FH : difficutl to assess
Vaginal bleeding (-), lochia rubra (+)
Operation wound : covered by gauze, surgical wound moist
Micturation : (+) via cathether, uop 60 cc hours
Defecation : (-), flatus (+)
Therapy
IVFD RL 20 gtt/i
- Inj. Ceftriaxon 1 g/12 hr
- Inj. Gentamycin 80 mg/8 hr
- Drip. Metronidazole 500 mg/8 hr
- Inj. Ranitidine 50 mg/12 hr
- Inj. Ketorolac 30 mg/8 hr
- Tab PCT 500 3x1
THANK YOU