KASUS NO

IDENTITY
Identity Husband Identity

Name : Mrs. C Name : Mr. M

MR : 00 72 48 79 Education : Bachelor
Age : 32 Years old Age : 37 Years old
Address : Padang Address : Padang
Ocupation : Neurology Resident Ocupation : Employee
Education : Bachelor
Admission date. : August 24rd, 2022
 CLINICAL DATA
Anamnese 24-08-2022 03.00 PM Previous illness history :
Patient came by herself to PONEK Dr. M. Djamil Hospital complained • There is no history of DM, hypertension, heart, renal, lung disease
with severe abdominal pain since 4 hours ago​.
• Severe abdominal pain has been felt since 4 hours ago Family illness history :
• Bleeding from vagina (-)​ • There were no history of congenital, psychiatric and contagious
• Meat-like tissue came out from the vagina (-)​​ disease
• Eye’s fish bubbles like tissue out from the vagina (-)​
• Pelvic pain referred to the groin (-)​ History of marriage : 1x, 2012
• Fluid leakage from the vagina (-)​ History of pregnancy/abortion/delivery : 3/2/0
• Bloody show from the vagina (-)​​ 1. 2019/abortus/curettage not performed
• First date of LMP 12-06-2022 EDD : 19-03-2023 2. 2021/abortus/curettage not performed
• Menstrual history : menarche at 12 years old, regular cycle 28 3. Current pregnancy
days, 4-5 days each cycle with the amount of  2-3 times pad
change/day, menstrual pain​(-)
• ANC : never control to obstetrician
• History early and late pregnancy : nausea (-), vomit (-), fluor albus
(-)​
• Cough (-) flu (-) fever (-) traveling (-) and history of contact with
confirmed COVID-19 about 2 weeks ago was denied​
• Travel history out of town (-), contact history with COVID-19
patient (-)​
 PHYSICAL EXAMINATION
Physical Examination Genitalia : V/U normal, vaginal bleeding (+) spotting
GA Cons BP HR RR T Inspeculo : Not performed
Mdt CMC 112/80 64 20 36.5
VT bimanual
Weight :  60 kg Vagina : Tumor (-)
Height  : 160 cm Portio : NP, size equal to an adult toe, cervical movement pain (+) OUE was closed
BMI :  24.0 ( normoweight) CUT : equal to duck egg size
AP : Right adnexal tenderness (+)
Eyes : Conjunctiva wasn’t anemic, Sclera Icteric (-/-) CD : protruded
Abdomen : Extremity :
Inspection : Not enlarge. Cicatrix (-) Physiologist Reflex +/+
Palpation : Tenderness (+) , rebound tenderness (+)
defans muscular (-)
 SUPPORTIVE EXAMINATION
PONEK Ultrasound: Aug 24th 2022  04.45 p.m  Laparotomy was performed
• Suspected ruptured ectopic pregnancy • Intra peritoneal blood 500 cc​
• Ruptured Ampula of Right tubal was seen -> Right salpingectomy​
Laboratory, Aug 24th 2022 • Uterus and left adnexal normal
Hb/Ht/Leu/Tro : 12.8/37/7.490/ 250.000 Protein total/GDS: 6.8/106 • Intra operative bleeding 500 cc​
Alb/Glo : 4.1/2.7 SGOT/SGPT : 17/21
PT/APTT : 10.9/19.7 Ur/Cr : 15/0.4 Diagnose Post Op :
Na/K/CL: 141/3.8/108 HbsAg/HIV : non reactive/non reactive • P0A3L0 post right salpingectomy due to ruptured ampula of right
tubal
Diagnose Pre Op :
• Acute abdomen due to suspected ruptured ectopic pregnancy on G3P0A2H0 10-11 Process :
weeks of pregnancy • Acute abdomen due to suspected ruptured ectopic pregnancy on
G3P0A2H0 10-11 weeks of pregnancy  Laparotomy  Rupture
Plan : tuba pars ampula dextra  Salpingectomy dextra
• Emergency Laparotomy
Instruction :
Instruction :
• Control GA, VS, Vaginal bleeding
• Control GA, VS
• Crossmatch 1 unit PRC • IVFD RL  20 dpm​​
• Pro Laparotomy • Inj. Ceftriaxone 2 x 1 gram IV​
• Informed consent • Pronalges supp II if needed​
• Anesthesiologist consult • Laboratory check 6 hours post op
• Prepare for emergency laparotomy • Care in HCU​
Admission Latter
Laboratorium
PONEK Ultrasound
PONEK Ultrasound
 PONEK Ultrasound

• Uterus anteflexion size 5.66 x 3.45 cm

• End line (+)
• There was complex of mass right ovarium 4.6 x 4.8 cm
• Free fluid (+)
• Left adnexa was normal

Impression :
Suspected ruptured ectopic pregnancy
Operation Report
• Patient on supine position under general
anesthesia
• Antiseptic and septic procedure was performed
• Midline incision was performed, layer by layer
was opened until peritoneum
• Exploration was performed, massive blood
clotting was found in abdominal cavity
• Conception was seen in pars ampularis of right
tuba
• Right salpingectomy was performed
• Bleeding observation was performed
• Abdomen was closed layer by layer
• Skin closed by subcuticular closure
• Intraoperative bleeding : 500 cc
Documentation
Documentation
Documentation
 Follow Up 2 Hours Post Op

S Post operative pain (+)​ P • Control GA, VS

• IVFD RL  20 dpm​​
• Inj. Ceftriaxone 2 x 1 gram IV​
• Pronalges supp II if needed​
• Laboratory check 6 hours post CS​
• Care in HCU​
O GA       Cons       BP         HR          RR       T        Urine​
Mdt      CM      128/77      82     20    36.6   250 cc/2hrs​
​
Abd : Operation wound closed by verband. 
Tenderness (-), rebound tenderness (-), defans muscular (-)
Genitalia : V/U normal. Vaginal bleeding (-)​

A • P0A2H0 post salpingectomy dextra oi rupture tuba pars ampula

dextra, POH 0
 Follow Up 25/08/2022 (08.00)

S Post operative pain (+)​ P • Control GA, VS

• IVFD RL  20 dpm​​
• Inj. Ceftriaxone 2 x 1 gram IV​
• Pronalges supp II if needed​

O GA       Cons       BP         HR          RR       T        Urine​
Mdt      CM      125/70      90     18    36.6   250 cc/2hrs​
​
Abd : Operation wound closed by verband.
Tenderness (-), rebound tenderness (-), defans muscular (-)
Genitalia : V/U normal. Vaginal bleeding (-)​

A • P0A2H0 post salpingectomy dextra oi rupture tuba pars ampula

dextra, POH 1
6 Hours Post Operative Laboratory
Thank You