CHAPTER II

CASE

SMF OBSTETRY AND GYNECOLOGY

HOSPITAL OF EMBUNG FATIMAH BATAM CITY

Medical Record : 174799

I. PATIENTS IDENTITY
Name : Mrs. RM
Age : 29 years old
Gender : Woman
Religion : Islam
Address : Ruli Bukit Rindang
Job : Housewife
Marital Status : Married
HPHT : 5 October 2016
Gestation : 26 - 27 weeks
Date of entry : 12 June 2017
Weight : 47 kg
Height : 149 cm

II. ANAMNESIS
Patient come to obstetrics poli with complaint like headche , feel tired and weak. Patient
come by her own self to obstetrics poli, hospital of embung fatimah on Tuesday, April
10th, 2017 at 10 am.

MAIN COMPLAINT
Headache , feel tired and weak

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HISTORY OF PRESENT ILLNESS
A woman 29 years old by her own self went to obstetrics poli, hospital of embung
fatimah, batam city with complaint like headche , feel tired and weak.
Pregnancy history, patient born her first child: boy, weight : 3000 gr by normal childborn
at clinic on 2015.

OBSTETRIC HISTORY
- Fisrt pregancy : Male. Spontaneous Delivery. 3000 gr. 2015
- Second pregnancy : now

PERIODS HISTORY
Patient admited, her first period at 14 years old. Her periods cycles regular every single
month. Periods cycles 28 days, for 3-5 days. LMLP is october 15th 2016.

MARITAL HISTORY
Married just once at 2014, she were 24 years old.

ANTENATAL CARE HISTORY

Patient always her pregnancy every month to hospital.

PREVIOUS MEDICAL AND OPERATIONS HISTORY

(-)

CONTRACEPTION HISTRORY
(-)

ALERGIC HISTORY
(-)
PREVIOUS ILLNESS HISTORY
(-)

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 FAMILYS ILLNESS HISTORY
(-)

III. PRESENT STATUS

GENERAL STATUS
General Condition : Good
Consciousness : Compos Mentis
Weight : 39 kg -> 47 kg
Height : 149 cm
BMI : 21.17 (Normal)
Blood Pressure : 100/60 mmHg
Heart Rate : 78x/m
Respirasi Rate : 18x/m
Temperature : 36,7 C

PHYSICAL EXAMINATION
Head : Conjungtivity : anemis (+/+)
sclera : ikterik (-/-)
Neck : Lymph gland : normal
Thyroid gland : normal
Thoraks : lung : - inspection : simetris
- Palpation: fokal fremitus dekstra//sinistra normal
- Percussion : sonor at all lungs path
- Auscultation : vesikuler (+/+), rhonki : (-/-), wheezing (-/-)
Heart : heart sound S1-S2 regular, murmur (-) gallop (-)
Abdomen : tense looking dan glowing (+),push pain (+), bowel sound (+), asites
(+)
Ekstremity : Edema : -/-
Varises: -/-
Akral : warm (+)

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IV. OBSTETRIC STATUS
Leopold Examination
Leopold I: Round, there is big part , soft at fundus uterus
Leopold II : hard to palpate
Leopold III : hard to palpate
Leopold IV : the bottom part of fetus is not at pelvis entrance (convergen)

Outside Examination :
Fundus of uteruss height : 23 cm
Fetus heart : 139x/m
Contraction : (-)
Vagina Touche :
(-)

V. LABORATORIUM
Routine Blood Test
Hb : 8 gr/dl
Leukocytes : 12.400
Ht : 27%
Eritrocytes : 3,3 million/ul
Trombocytes : 218 thousand/ul
Blood Group : O Rh+
HIV : negatif
HbSAg : negatif
Blood Glucose : 128 mg/dl

VI. DIAGNOSE
G2P1A0H1 gravid 26 - 27 weeks + Anemia

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Follow up at ward
Date : April 10th 2017
S Patient headache nd feel tired
General status : Good
consciousness : Compos mentis
blood ressure : 100/70 mmHg
heart rate: 80x/m
Respiratory rate: 18x/m
Temperatur : 36,5 C
Fetus heart : 140x/m
Infuse (+)
Eyes : ca (+/+) si(-/-)
O
Thorax : DBN
Abdomen : bowel (+), asites (+), tegang (+), nyeri tekan (+)
Leopold examination:
Leopold I: there is big part, circle, soft at fundus of uterus.
Leopold II : unpredictable
Leopold III : unpredictable
Leopold IV : the bottom part of fetus is not at pelvis
entrance. (convergen)
Ekstremity : warm (+), udeme (-)
A G2P1A0H1 gravid 26 - 27 weeks + Anemia
Observation condition and vital sign of patient
Suggest patient to rest

P
Tranfusion 2 Kolf PRC Premed Ondancentron +
Dexamethason
Check blood after transfusion

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 Date : April 11th 2017
S (-)
O General status : good
consciousness : compos mentis
blood ressure : 120/70 mmHg
heart rate: 80x/m
Respiratory rate: 19x/m
Temperatur : 36,5 C
Fetus heart : 135x/i
Infuse (+)
Eyes : ca (-) si(-)
Thorax : DBN
Abdomen : bowel (+)
Leopold examination:
Leopold I: there is big part, circle, soft at fundus of uterus.
Leopold II : unpredictable
Leopold III : unpredictable
Leopold IV : the bottom part of fetus is not at pelvis
entrance. (convergen)
Ekstremity : warm (+), udeme (-)
A G2P1A0H1 gravid 26 - 27 weeks + Anemia
VII. RESUME
Patient 29 years old, G2P1A0H1 gravid 26-27 weeks with Anemia. Patient admit she did
normal child born and born a boy with weight 3000 gram in clinic at 2015, and this is her
second pregnancy.

At April 10th 2017 on 10 am, patient come by her own self to obstetrics poli hospital of
embung fatimah, batam city with complaint like headche , feel tired and weak. Observation
result, general condition : good, blood pressure = 100/60 mmHg, heart rate= 78x/i,
respiratory rate : 19x/m, temperatur = 36,7c, fetus heart = 140x/m.

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