Name : Afrida Yeni

Age : 22 yo
Adress : Ganting No 84
MR No : 28 9452
Date : October 18
t
2!!2
Anamnesis
A 22 Years o"d #atient $as admitted to te De"i%ery Room of Dr& M& D'ami" (entra"
Genera" )os#ita" on October 18
t
at !1 !5 $it cief com#"ain #ain a"" regio of te
abdomen
Present Illness History :
*ain a"" regio of abdomen since 9 o+rs ago&
,sca#ed b"ood from %agina $as absent - fe%er $as absent- f"+or $as absent
)istory of tra+ma $as absent
.e #atient tat se $as #regnant 1 mont ago - e/amine at #+s0esmas&
.e #atien $as maried 1 year ago
)er +sband $or0 as nongo%erment em#"oye
Menstr+ation )istory : menarce at 14 years o"d- reg+"ar cyc"e- e%ery 28 days
$ic "ast for 5 to 1 days eac cyc"e $it te amo+nt of 223 times #ad cange
4day menstr+a" #ain $as #resent&

Previous illness history
No im#ortance
Family illness history
No im#ortance
Marriage istory : Once at 2!!1
)istory of #regnancy4Abortion4De"i%ery : 14!4!
5 *resent

(ontrace#tion istory : none
5mm+ni6ation istory : none
Physical Examination
Genera" a##earance : Moderate
(onscio+snes : 7+""y conscio+s and coo#erati%e
8"ood #ress+re : 8!49! mm)g
*+"se Rate : 99/4m
Res#iration rate : 24/4m
.em#erat+re : 31 (
,yes : (on'+ncti%a anemic - :c"era not icteric
Nec0 : ;<* 522 cm )2O - .yroid not en"arge
(est : )4= Norma"
Abdoment : GR
Genita"ia : GR
,/tremity : ,dema 242 - *ysio"ogica" Ref"e/ >4> - *ato"ogica" Ref"e/ 242
Gynecologic Record
7ace : .e #regnancy sign $as ?>@
8reast : .e #regnancy sign $as ?>@
Abdomen :
5ns#ection : :"igt"y ,n"arged and distended
.igt- %enectation ?2@
*a"#ation : M+sc+"ar defense ?>@- *res+re #ain ?>@-
Re"ease #ain ?>@
*erc+sion : :ifting d+""ness canAt be e%a"+ated
A+sc+"tation : #erista"tic so+nd ?>@ decreased

Genita"ia :
5 :<+"%a4Bretra norma"
5ns#ec+"o :
<agina : 7"+/+s ?>@ sma"" amo+nt dar0 red- 7"o+r ?2@ =aceration ?2@- .+mor ?2@-
(ad$ic0 sign ?>@

*ortio : N*- :i6e eC+a" to and ad+"t foot toe- #osterior-f"+/+s ?>@ sma""-amo+nt
Dar0 red 7"o+r ?2@ =aceration ?2@- .+mor ?2@
OB, c"osed

8iman+a"4 <. : <agina : t+mor ?2@
*ortio : M* :i6e eC+a" to and ad+"t foot toe- #osterior- t+mor ?2@
OB, ("osed- sa0y #ain ?>@
(B. : canAt be e%a"+ated
A* : canAt be e%a"+ated
(D : *ress+re #ain ?>@- #rotr+ded
R. : An+s norma"- s#incter in good condition- m+cose smoot- am#+"ar em#ty-
.+mor ?2@
Laboratory
)b : 9-2 gr D
=e+0ocyte : 291!!
(. : 4A3!E
8. : 2A3!E
.rombocyte : 299& !!!
*"ano test : ?>@
WD4 Ac+te abdomen ec dist+rbing ecto#ic #regnancy > gra%es anemia
Attitude :
Fards #re o#
*re#ared =a#arotomy
*re#ared b"ood 15!! cc
(ontro"e <:- **<
(ons+"t O#eration Room- Anastesi
Plan
=a#arotomy
=a#arotomy begin at !4 55 am
=a#arotomy $as #erformed&
After te #eritone+m $as o#ened tere $as b"ood and b"ood c"ot fi""ed te abdomen
ca%ity- ,%ac+ated b"ood from it 15!! cc- ,/#"oration $as #erformed- Bter+s as big as
d+c0 egg&
=eft .+ba and o%arian sa#e and si6e $as norma"
7o+nd r+#t+red at Rigt .+ba #ars istmica
5m#resion : R+#t+red of rigt t+ba #ars 5stmica
*"an : Rigt :a"#ingectomy
Diagnosed:
*ost Rigt :a"#ingectomy on indication R+#t+re rigt t+ba #ars istmica