June 6, 2013
Patient Identity
Date of Admition Time Origin Name Age Education Occupation Religion Tribe Address : 6 June 2013 : 21. 43 WIB : UGD : Mrs. B : 35 years old : Senior High School : Housewife : Christian : Batak : Jl. Asyafiliah RT 03 RW 03 Kel. Cilangkap
I. Subjektif
1. Chief Complain :
Bleeding from vagina
2. Additional Complain
Abdominal pain
Menstruation History
a. First Period b. Circulation of menstrual Cycle Length Amount Period Pain (dismenorrhea) Having drug : 14 years old : Regular : 4 days : 2 changes / 80 cc : none : none
Marital History
a. Marital Status b. Last Marriage : Married : 3 years
Previous illnesses
: dust allergy
: denied
: denied : denied
Others Data
None
General Examination
Vital sign
Height Weight Body mass index General condition Consciousness Blood pressure Pulse Temperature Respiratory rate : 150 cm : 57 kg : 25, 3 : seem moderate illness : compos mentis : 100 / 80 mmHg : 72 x / minutes : 36,8 o C : 19 x / minutes
Head
Eyes :
Anemic conjunctiva Icteric sclera :-/: - /-
Teeth Ear
CAE Cerumen
Nose
Cavum nasal Fluid
:
: wide /wide : - /: T1 - T1, red : red
Throat
Tonsil Faring
Neck
Enlarged lymph nodes Tenderness :-/:-/-
Thorax
Heart : Heart sounds 1 and 2 normal, regular, murmurs (-), gallops (-) Lungs : chest wall movement symetric, percussion : resonant / resonant, base breath sounds : vesicular , ronkhi - / -, wheezing /-
Abdomen
Inspection : looks flat Palpation : soft, tenderness (-), muscular defense (-), liver and spleen not palpable enlarged Percussion : tymphany Auscultation : bowel sounds (+) 4 x / minutes
Extrimities
Superior Inferior : warm akral, cap refill time < 2, edema -/: warm akral, cap refill time < 2, edema -/-
Outer Examination
Face Mammae : round shape :
Mass : -/ Retraction : -/ Pain : -/-
Abdomen
looks flat, soft, tenderness (-), muscular defense (-), liver and spleen not palpable enlarged, tymphany, bowel sounds (+) 4 x / minutes
External genitalia
Pubic hair distribution Fluksus : (+), not active fluor : none Vulva : mass (-), pink : distributed equally
: pink, fluksus (-) : rugae (+), mass (-) : round shape, chewy consistency : anteflexion position, shaky pain (-)
Douglas cavity
Assesment
Working diagnose
G2P1A0, 7 weeks pregnant + Abortus incomplete
Differential diagnose
Abortus imminens
Prognosis
Ad vitam Ad functionum Ad sanationum : bonam : bonam : dubia ad bonam
Problem list
Active Passive : Bleeding from vagina, Abdominal pain :-
Planning
1. Diagnostic planning
Lab : Hemoglobin, Hematocrit, Leukocyt, Trombocyt USG
2.
Management planning
Inpatient Vital sign observation, and bleeding observation Lab and USG examination Curettage planning Diet : fasting IVFD : RL 20 drops /minutes MM : Kedacillin 3 x 1 gr (IV) Methergin 3 x 0,125 mg (IV) Kaltrofen supp 2x1
3.
Education planning
Explain to the patient about her pregnancy and plans will be performed, Motivation patient for KB