STATUS OBGYN UNIVERSITY Malahayati Identity Name: Mrs.

F Age: 35 years Religion: Islam Occupation: Housewife Marital Status: Married Address: Pringkumpul, Pringewu Tribe: Lampung

Husband Name: Mr. W Age: 35 years Religion: Islam Occupation: Labour Marital Status: Married Address: Pringkumpul, Pringewu Tribe: Lampung Hospital Admission Date: May 14, 2012 Hours 22:00 pm Check the date: May 14, 2012 Hours 23:00 pm

Anamnesis Main complaints: stomach mules continue - again History of Disease Now: FT mother complained perfect stomach since 8 pm, perfect stomach continues to be felt - and again. Mother also admitted to discharge from the penis, colorless liquid that comes out cloudy, fluid is accompanied by mucus, and not accompanied by blood.The first time the patient felt a little discharge while a mild activity (sweep). When the discharge mothers can still feel the fetal movements, mother also

felt the mules since 6 pm yesterday, mules felt intermittent, at the time running mules are not felt. Mules felt continuously until now when the rest mules still felt. Mothers feel nausea, vomiting, dizziness and blurred vision. Patients feel pain waist area since yesterday afternoon, the pain is felt tingling.Patients also experience pain since this morning suprapubic, intermittent pain is felt. BAK little but often. The patient also complained of difficulty CHAPTER since this morning. Mother admitted having vaginal discharge.

In the past history of disease • Hypertension History of Medicine • Not to get treatment History of Allergy • Allergy drugs Ampicillin and Ceftriaxon Family History • No one had the same complaints as the patient • No high blood pressure • There is no sugar disease • There is no heart disease • No renal disease • There is no lung disease • There is no birth defects Historical Trauma and Surgery • It's never had an accident or operation of the content Previous Medical History • No previous disease Special History of Obstetrics

A. Pregnancy history now: • First Menstruation: Age 15 years • Menstruation: Regular • Cycle: 6 days • Pain during menstruation: Often pain • The amount of menstrual blood comes out: a lot • HPHT: August 7, 2011 • Estimated Date of Birth: May 15, 2012 • Pregnancy: 30 weeks • ANC: 2x The Midwife • Immunization TT: 2x at month 7 and 8

2. History of Childbirth: • His: 2x10 'for 20 " • Mucus since: May 10, 2012 from 07.00 pm • Sense of straining: (-) • Membranes: seeped

History System a. Status Generalis • Examination Time: May 14, 2012 at 23:00 pm • General condition: Good • Awareness: Compos Mentis • Vital Sign: o Blood Pressure 160/100 mmHg o Nadi 84 x / minute o Shortness of 24 x / minute The temperature of 36.7 ° C • Uterus: a thick soft lower portion • SFH: 30 cm • His: (+) 2x10 'in 20 " • Conjunctiva anemis: - / -

2. Physical examination: • Head: o Hair: Not easily removed o Eyes: sclera jaundice - / - conjunctiva anemis - / - pupil isokor direct reflex + / + Indirect + / + strabismus - / - there is no sign of inflammation of the left and right o Ear: wax - / - hearing both + / + tender tragus - / - MAE symmetrical left and right, the tympanic membrane intact + / + o Nose: secretions - / - septum nasi no deviation mucosal hiperemis - / - hypertrophy Konka - / - Mucous - / - Blood - / - polyps - / - o Mouth: Lips: normal Tongue: no tremor, no gross Dental: no plaque, no cavities Pharynx: not hiperemis Tonsils: T1/T1 uvula: there are no signs of inflammation • Neck: o Hyperpigmentation o BEC: No enlargement o JVP: 5 +1 cm H2O

o Trachea: There is no deviation o thyroid: No enlargement • Thorax: o Anterior Lung: Inspection: Hyperpigmentation mammary areola, sikatrik - / - lag breathe - / - lump - / -, lesion - / Palpation: normal fremitus symmetrical, tender - / -, crepitus - / -, mass - / -, left-right symmetric static dynamic Percussion: resonant throughout the lung fields + / + auscultation: vesicular throughout the lung fields + / + o Posterior Lung: Inspection: Gibus -, lump - / -, normal vertebrae Palpation: tender - / -, the mass - / -, fremitus symmetrical normal Percussion: resonant dektra the left throughout the lung fields auscultation: vesicular throughout the lung fields + / + o Heart: Inspection: Iktus cardiac invisible Palpation: no palpable cardiac iktus Percussion: no enlargement of the heart Auscultation: BJ 1 and 2 • Abdomen: o Inspection: no sikatrik, no caput medusa, o Auscultation: not rated o Palpation: No tenderness o Percussion: not rated • Urogenital: o External Genitalia: The vagina and the vulva appears red External urethral ostia with no signs of inflammation There is no injury o Anus: There is no injury • Extremities: o Edema: + / +

o Varicose veins: - / o Muscle strength 4/4/4/4 physiological reflex o + / + pathological reflexes o - / normal sensibility o + / + Status of Obstetrics: Outside the abdominal examination (May 14, 2012 at 23:00) • fundus Height: 30 cm • DJJ: 154x/menit irregular • The location of the fetus: Leopold I: palpable breech fetuses Leopold II: the fetal extremities, Puka Leopold III: Oblique head presentation Leopold IV: I Hodge - Hodge II • Reduction: no • HIS: (-) Examination (vaginal toucher) • The opening of 1 cm • thick soft lower portion • Membranes seeps Examination Support • Complete Blood Examination o Hb o Ht o Erythrocytes o Platelets o Leukocytes o BT o CT o aPTT o PTT o Levels of Fibrinogen o GDS • Urine Routine Examination o The volume of urine

o BJ urine o Protein o Erythrocytes o Leukocytes o Epithelial • USG Seem to fall head with lies oblique presentation

The diagnosis: • G1P0A0 Preeclampsia Pregnancy 30 weeks with fetal weight and Primitua single suspect live with Oblique

Management: • Infusion + RL oxytosin 5 iu • Gentamicin 1 gr/12 hours • Insert the catheter • Fast pre-SC Consultation • The specialist OBGYN