Case 3

Name : Mrs. D.S

Age : 20 yo
Address : Bug-bug Selatan, Lingsar
Admitted : 29 June 2016
TIME SUBJECTIVE OBJECTIVE ASSESSMENT PLANNING

29/06/ Patient referred from Lingsar PHC General status G1P0A0L0 40-41 DM planning:
2016 with G1P0A0L0, 40 weeks S/L/IU GC: well weeks S/L/IU head Diagnostic:
21.00 head presentation, mother and fetal GCS : E4V5M6 presentation with Check CBC,
in good condition with gestational BP : 120/70 mmHg PROM < 12 hours HbsAg
hypertension + PROM <12 hours. HR: 90 tpm CTG
Patient confessed water leaked from RR: 20 tpm
her womb since 29/06/2016 at Tax: 36.6 C Therapy:
19.00, bloody slime (+), abdominal Obs mother and
pain (-) , fetal movement (+). Localis status fetal well being in
Eye : an (-/-), ict (-/-) hospital every 4
History of DM (-), HT (-), asthma (+), Pulmo ves (+/+), rh (-/-), wh (-/-) hours
allergic (-) Cor : S1S2 single regular, murmur Obs progress of
History DM in family (-), HT (-), (-), gallop(-) labor
asthma (-), allergic (-) Abdomen: Injection ampicilin
Scar (-), striae gravidarum (+), 2 gr iv, continue
LMP : 20-09-2015 linea nigra (+) with oral ampicillin
EDD: 27-06-2016 Extremity: oedema (-/-) warm (+/ tab 3x500 mg
GW : 40-41 weeks +)
DM co to GP, GP co
History of ANC: 11x at PHC, last Obs status: to Spv, advice:
ANC 27/6/2016, result patient L1 : breech - Therapy based on
confessed pain in the flank, dizzy; L2 : back to the right side NTB GH Guideline
BP 160/110 mmHg, the patient was L3 : head on PROM
given nifedipin 2x0,5 and vitamin B1 L4: 4/5
2x1 UFH: 30 cm
EFW : 2945 g
History of USG: - FHB : 12-12-12
UC : -
History of family planning: - Inspeculo : clear fluid at fornix
Next family planning: : injection 3 posterior
months VT : 2 cm, eff 25%, amnion (-),
Obstetrical history: head persentation, denom
1. this unclear, HI, small parts and
umbilical not palpable
TIME SUBJECTIVE OBJECTIVE ASSESSMENT PLANNING

Chronology at Lingsar PHC Laboratory exam (29/06/2016):

(29/06/2016) 20.00: HGB: 12,6
S/ RBC: 4,29
Patient 9 month pregnant confessed HCT: 27,6
water leaked out from her womb since MCV: 89,3
29/06/2016 at 19.00. Bloody slime (+), MCH: 26,4
FM (+) MCHC: 31,5
O/ WBC: 7,08
GC: well PLT: 152
BP : 150/80 mmHg
HR: 80 tpm CTG : Reactive
RR: 20 tpm
Tax: 36.5 C
UFH : 34 cm
Head Presentation, back on the right
side, L4: 4/5.
EFW : 3565 gram
UC : -
FHB: 132 (11-11-11) bpm
VT : 2 cm, eff 25%, amnion (-), head
persentation, denom unclear, HI,
small parts and umbilical not palpable
Proteinuria (-)
A/
G1P0A0L0 40 weeks S/L/IU head
presentation, mother and fetal in good
condition, with gestational
hypertension + PROM <12 hours
P/
20.05 Skin test ampicillin result (-)
20.20 Injection ampicillin 1 gr iv
Infuse RL 28 dpm
TIME SUBJECTIVE OBJECTIVE ASSESSMENT PLANNING

01.00 Abdominal pain (+), fetal BP : 110/70 mmHg G1P0A0L0 40-41 Obs mother and fetal well being
movement (+), water HR: 100 tpm weeks S/L/IU head Obs progress of labor every 4
leaked from her womb (+) RR: 19 tpm presentation with hours
Tax: 36.7 C ROM + Latent phase
UC : 2x10~30 of labor
FHB : 13-12-12
VT : 2 cm, eff 25%,
amnion (-) clear, head
persentation, denom
unclear, HI, small parts
and umbilical not
palpable

05.00 Abdominal pain (+), fetal BP : 110/70 mmHg G1P0A0L0 40-41 Obs mother and fetal well being
movement (+), water HR: 100 tpm weeks S/L/IU head Pro c-section
leaked from her womb (+) RR: 18 tpm presentation with
Tax: 36.8 C ROM + Latent phase
UC : 3x10~35 of labor + fetal DM co to GP. GP co to spv :
FHB : 12-12-12 distress Pro c-section
VT : 5 cm, eff 50%,
amnion (-) meconeal,
head persentation,
denom unclear, HI,
small parts and umbilical
not palpable
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