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laporan C A S E 5 !!!!!

laporan C A S E 5 !!!!!

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Published by Nita Andriyani

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Published by: Nita Andriyani on Nov 13, 2011
Copyright:Attribution Non-commercial

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11/24/2012

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Tutorial 1 step 1
Mrs. Adisty, a 39 year old G3P1A1, is referred to the MHC clinic in her34 week pregnancy because of mild discomfort at the upper leftabdominal part. She noticed that everytime her baby moves;somethink that she said she had never experienced before. She alsocomplains a bit tense on her lower tummy and afraid of recurrenthaving preterm birth.When the doctor asked, mrs. Adisty had started some contraction, butthere is no water broke, no bloody or slimy discharge from her vagina.She admits that the baby is still moving now.
Previous obstetric history.
She knew that she had arcuate uterus from hysterosalphyngogramprior to her first pregnancy.Her first pregnancy ends with spontaneous miscarriage, but the secondone she had a spontaneous pre-term birt, weighing 2000grm. Her sonis a healthy 3-year old now. She sad an incision of vaginal septum onprevious delivery. She sad normal lab exams performed a few weeksbefore.
Her physical diagnosis
is shown below:BP:120/80mmHg, PR:72/m, RR:20/m, T:35 CHeart and lungs: within normal limitOther: within normal limit
Obstetric examination
Uterin fundus 30 cm above symphisisLeopold 1 : a globular round hard mass is occupying the uterinefundus.
 
Leopold 2 : small fetal part detected on the left abdominal wall, on therigh side a long flat area of mass with higher resistence is detected onthe right sideLeopold 3 : some soft mass is palpable above the symphisis, andhave somehow entered the pelvic inlet.Contraction: once on every 10 minutes, weakAuscultation (laennec stethoscope) :Fetal heart breat could be easily and more clearly heard just above theumbilicus.Fetal heart rate : 144-152 beat per minuteSpeculum examination: Vulva/Vagina : no abnormalitiesCervical dilatation : nonePelvic examination : normal
Tutorial 1 step 2
She was referred to the feto-maternal clinic at the nearest districthospital.She came back, bringing the result of USG as follows:A singleton fetus, female, in brerch presentation, the back is on theright.Biometrical measurements are in accordance with a 34-36 weeks’pregnancy.Heart rate is normal.Estimated fetal weight is 2200 + 3000grm.No major congenital anomalies detected. The plasenta lies in the anterior body of the uterus not occupying theinternal uterine ostium.
Amniotic fluid index
: 12cm.
Conclusion:
G3P1A1 34-35 weeks pregnancy, breech presentation.
 
 The doctor prescribed oral tocolysis and explained the alarming signsas when the patient should return prior to the scheduled follow up visit.
Tutorial 2
Mrs. Adisty returned three weeks later to the MCH clinic, complainingthat she has been having regular contractions for 8 hours. She knowsthe baby is sill moving, no water broke.
Physical diagnosis
:Vital signs: within normal limitsObstetric examinationUterine fundus 30 cm above symphisis.Leopold 1 : a globular round hard mass is occupying the uterinefundus.Leopold 2 : small fetal part detected on the left abdominal wall, on therigh side a long flat area of mass with higher resistence is detected onthe right sideLeopold 3 : some soft mass is palpable above the symphisis, andhave somehow entered the pelvic inlet.Estimated fetal weight 2700 grmContraction: once every 3 minutes, lasting 50 second, strong.Fetal heart rate: 152-160 beat per minute
Vaginal examination
Vulva/vagina : no abnormalitiesPortio : axial position, soft, effacement 80%Cervical dilatation : 9-10 cmAmniotic membrane : intact

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