Case Report

Identity
Name: Mrs. M
Age: 24 years old
Adress: Sedayu, kediri
Hospitalization at 24
th
May 2014 at 02.13
Time Subject Object Assasstment Planning
24/05/20
14
02.25
Patient reffered from dr. Sp.OG with
G1P0A0L0, 34-35wk G/L-L/IU head-
head presentation with PPI. Patien
confessed water leaked out from her
vagina since 01.30 (24-5-2014).
Abdominal pain (-), Bloody slim (-).
FM (+).
History of HT (-), DM (-), asthma (-).

LMP : 18 09 - 2013
EDD : 25 6 - 2014
History ANC : 12x at PHC, last ANC
14-05-2014 result : gemeli, 33-34wk,
head-head pres BP: 110/70
USG: >4x last 23/5/2014 result:-

History of family planning:
Next family planning :

Obstetric History:
1. This

Chronology:-


General status
GC : well
BP : 130/80 mmHg
PR: 86 bpm
RR: 20 tpm
T: 36,3C

Local status
Eye : an (-/-), ict (-/-)
Pulmo: ves (+/+), rh (-/-), wh (-/-)
Cor : S1S2 single regular M(-),
G(-)
Abd : strie gravdarum (+), linia
nigra(+), scar(-)
Upper Ext : edema (-/-)
Lower Ext: edema (-/-)

Obstetric status
L1 : breech UFH : 34cm
L2 : back on left and right side
L3 : head, head
L4 : 5/5
TBJ :-
UC :-
FHB : I. 136x/min; II. 140x/min

VT : -, fornix palpable
immpressien head

PE
Promontorium not palpable
Spina ischiadika not prominen
Os coccy mobile
Arcus pubis >90

G1P0A0L0 35-36
weeks/G/L-L/IU head-
head pres with PROM
<12 hours
-Obs mother and fetal well
being
-Chek DL, HbsAg, BT,CT
-DM co to GP pro
conservative , inj ampi. ,
GP adv:
- inj. Amp, skin test (-)
inj. Ampi 1gr IV
(03.05)
- Observation inpatu
- Patient moved to VK
teratai
Time Subject Object Assessment Planning
Lab:
Hb: 13,4 g/dl BT: 210
RBC: 4.65 CT: 600
HCT: 39,4%
WBC: 12,40
PLT: 227
HbSAg: reagen empty

03.45 (VK
teratai)
General status
BP : 100/80 mmHg
PR: 80 bpm
RR: 20 tpm
T: 36,5C

Status Obstetric
UC: 1x10 10
FHB: (+/+) I. 152 bpm, II. 140 bpm


G1P0A0L0 35-36
weeks/G/L-L/IU head-
head pres with PROM <12
hours
- Obs mother and fetal
well being
- Sugeest patient to eat
drink and lay down to
left side
- Observation inpartu


09.00 Patient confessed
abdominal pain
General status
GC : well
BP : 110/90 mmHg
PR: 86 bpm
RR: 20 tpm
T: 36,1C
Obstetric status
UC: 2x10-20
FHB: I. 142tpm; II. 148
VT : -, fornix palpable immpressien
head, amnion leak

- Obs mother and fetal
well being
- Sugeest patient to eat
drink and lay down to
left side
- DM co to spv pro USG
- Spv adv;
- Induction of labor with
oxy
- Inj. Ampi 1gr iv, next
oral amoxicillin
3x500mg
- CIE family, acc
induction
Time Subject Object Assessment Planning