Solok, West Sumatera, Indonesia, September 26th 2018

To : …………………………………………..
…………………………………………………
…………………………………………………

Dear ………………………………………….,

The following is a summary of the medical record of :

History of pregnancy :
 This patient is known being pregnant since 3 months ago by last menstrual
period was June 29th 2018
 There is no significant health complaint during pregnancy
 This is her first pregnancy
 There are no sistemic, infectious, congenital and psychiatric disorder
Physical Examination :
 Vital sign is in normal limit
 Obtetric State :
o Abdomen : uterine fundal was palpable 2 fingers above pubic
symphysis, Fetal Heart Sound : 150-160 times/minutes
o Genitalia : in normal limit

Laboratory Report :
Hamoglobin : 12,6 gr/ml
Leukocytes : 12.400/mm3
Trombocyte : 375.000/mm3
Random blood glucose : 110 mg%
Anti Toxo IgG : (-)
Anti Toxo IgM : (-)
Anti Rubella IgG : (+)
Anti Rubella IgM : (-)
Anti CMV IgG : (+)
Anti CMV IgM : (-)
Anti HSV IgG : (-)
Anti HSV IgM : (-)
Urinalysis : in normal limit
The ultrasonography procedure was done 4 times for this patient, by following
result :
 I (20/8/18) : Intrauterine single fetus, CRL (0,58), FHR (+), impression : 6-7
weeks pregnancy
 I (31/8/18) : Intrauterine single fetus, CRL (1,71), FHR (+), impression : 7-8
weeks pregnancy
 II (13/9/18) : Intrauterine single fetus, CRL (2,94), FHR (+), impression : 9-
10 weeks pregnancy
 III (26/9/18) : Intrauterine single fetus, CRL (4,83), FHR (+), NT : 1 mm,
impression : 11-12 weeks pregnancy, EDD : April 10th 2019

Final Diagnose :
G1P0A0L0 11-12 weeks pregnancy, fetal alive singleton intrauterine
So this medical record was made to be used as best as possible for related purposes.

Signed :