Case Report

Name : Mrs. S
Age : 25 yo
Address : Narmada, Perejak
Admitted : April 3rd, 2017
Time Subjective Objective Assessment Planning

Lab:
HB: 13,1 g/dl
RBC: 4,28 M/dl
WBC: 8,69 K/dl
PLT: 314
HbSAg: (-)
 Time Subjective Objective Assessment Planning

(03/04/2017 Chronologist At Pratama Awet Muda

,
) Hospital Narmada:
18.30 S : Patient pregnant 9 month confessed water
leaked out from her womb since (03-04-
2017) at 08.00 am, Bloody Slime (-),
abdominal pain (-), FM (+)

O;
General status
GC : well
GCS: CM (E4V5M6)
BP : 110/70mmHg
PR: 80 tpm
RR: 20 tpm
Tax: 36,8C

Obsetrical status :
L1 ; breech
L2 ; back on the right side
L3 ; head
L4 ; 4/5
UFH : 34 cm
EFW: 3100 gram
FHB: 150x/m
UC: -
VT : no dilatation , eff. (-)
A ; G1P0A0L0 38 weeks S/L/IU head
presentation mother and fetal in good
condition + PROM + oligohidramnion

P ; IVFD RL 20 dpm
Inj. Ampicilin 1 gr IM (14.30)
Skin Test -
 Time Subjective Objective Assessment Planning

17/06/2016 Abdominal pain (+), General status G1P0A0L0 38-39 weeks DM Planning:
23.00 AM GC : well S/L/IU head presentation + Termination
GCS: CM (E4V5M6)
BP : 130/80mmHg
PR: 86 tpm
.,l; PROM < 12 hours + Susp
CPD
perabdominal with C-
Section

RR: 20 tpm
T: 36,5C
UC: 2x10~ 25
FHB: 12-13.-12 (148bpm)
VT : 1 cm, eff. 25%, Amnion
(-) clear, head palpable

00.30 AM Abdominal Pain (+) General status G1P0A0L0 38-39 weeks DM Planning:
GC : well S/L/IU head presentation + Termination
GCS: CM (E4V5M6) PROM > 12 hours + Susp perabdominam with C-
BP : 120/70mmHg CPD Section
PR: 82 tpm
RR: 18 tpm DM co to GP, GP co to
T: 36,5C SPV, SPV advice:
UC: 2x10~ 25 C-Section this morning
FHB: 12-12.-12 (144bpm) at 08.00 AM

04.30 AM Abdominal Pain (+) General status G1P0A0L0 38-39 weeks DM Planning:
GC : well S/L/IU head presentation + Termination
GCS: CM (E4V5M6) PROM > 12 hours + Susp perabdominam with C-
BP : 120/80mmHg CPD Section
PR: 80 tpm
RR: 18 tpm
T: 36,6C
UC: 2x10~ 30
FHB: 12-13.-12 (148bpm)
VT : 1 cm, eff. 25%, Amnion
(-) clear, head palpable
 Time Subjective Objective Assessment Planning

06.00 AM Abdominal Pain (+) General status G1P0A0L0 38-39 weeks DM Planning:
GC : well S/L/IU head presentation + Termination
GCS: CM (E4V5M6) PROM > 12 hours + Susp perabdominam with C-
BP : 120/80mmHg CPD Section
PR: 84 tpm
RR: 18 tpm
T: 36,6C
UC: 2x10~ 30
FHB: 12-12.-12 (144bpm)