Name : Ms.

T
RM : 504656
Age : 25 years old
Address : Batu Layar
Admitted : February 6th 2013, 13.45
WITA
TIME SUBJECTIVE OBJECTIVE ASSESSMENT PLANNING
06/0 Patient come alone General Status : Abortus Infuse RL
2/20 confessed blood came GC/GCS : weak, E4V5M6 mola rapid
13 out from her womb since BP : 80/40 mmHg hidatidosa + O2 3 lpm
13.4 09.00 (06-02-2013). PR : 100 bpm hypovolemic DM consult to
5 abdominal pain (+). RR : 28 bpm shock GP, pro curetage
Patients admitted 3 Temp : 36oC GP co to SPV
month pregnant and has advice
pregnancy test, result Eye : pallor (+/+), icteric observation,
(+). Patient has a history (-/-) gave
for use drug gastrul 4 tab Cor : S1S2 single regular, uterotonica,
pervaginam. murmur (-), gallop (-). double line (RL
Pulmo : vesicular (+/+), and RL+Oxy)
LMP : forget wheezing (-/-), ronkhi (-/-). CIE patient and
History of USG : never Abdomen : enlarged family.
History of family planning abdomen (-), defense
: muscular (-), pain
tenderness (-), UFH 3
Obstetrical History : finger below umbilical.
1. This Extremity : edema (-/-),
warm acral (-/-).

Gynecology Status :
Inspeculo : (+), erosi (-),
livide (+), fluxus (+),
active bleeding (-), fluor
(-), bubble of mola (+)
VT : (+), tissue
palpable, slinger pain (-),
bubble of mola (+).
TIM SUBJECTIVE OBJECTIVE ASSESSMENT PLANNING
E
Lab Examination :
HB : 9,8 g/dl
RBC : 3,18 M/L
WBC : 12,24 K/L
PLT : 219 K/L
HCT : 28,9 %
HbSAg : (-)

21.0 Bloody came out from her GC/GCS : weak, DM consult to

0 wombs E4V5M6 GP, pro
BP : 80/60 mmHg transfusion PRC
PR : 90 bpm 4 kolf GP co to
RR : 26 bpm SPV advice
Temp : 37oC observation,
gave oxy IM and
Active bleeding (+) continue oxy
drip, pro
Lab Examination : transfusion PRC
HB : 4,4 g/dl 3 kolf and WB 1
RBC : 1,42 M/L kolf
WBC : 6,,53 K/L
PLT : 100 K/L
HCT : 13,1 %

00.0 Bloody came out from her GC/GCS : weak, observation at

0 wombs E4V5M6 MELATI every 30
BP : 90/60 mmHg minute until
PR : 82 bpm stable
RR : 24 bpm
Temp : 37oC
TIM SUBJECTIVE OBJECTIVE ASSESSMENT PLANNING
E
00.3 GC/GCS : weak,
0 E4V5M6
BP : 90/60 mmHg
PR : 82 bpm
RR : 22 bpm
Temp : 36,6oC

01.0 GC/GCS : weak,

0 E4V5M6
BP : 90/60 mmHg
PR : 84 bpm
RR : 22 bpm
Temp : 36,5oC

01.3 GC/GCS : weak,

0 E4V5M6
BP : 90/60 mmHg
PR : 80 bpm
RR : 22 bpm
Temp : 36,5oC
TIM SUBJECTIVE OBJECTIVE ASSESSMENT PLANNING
E
07.0 GC/GCS : weak,
0 E4V5M6
BP : 100/60 mmHg
PR : 84 bpm
RR : 22 bpm
Temp : 36,9oC