1.

Vita Listia Setya Dewi (P1337424117010)

2. Erni Fadhlina (P1337424117027)

Chief complaint:

“dizzy, nausea and vomiting, weak, pale”

History of present illnes:

Mrs. S, 25 years old 18 pregnancy, has dizzy, nausea and vomiting, weak and pale. From the
analysis result can be concluded that Mrs. X has anemia. This can be happened because of
worse dietary habit. The example is she never eat chlorophyl and Mrs. X is too worry about
her pregnancy.

Surgical history:

Never

Past sickness history:

Never

Social history:

Patient live with her husband, patient is not go work and she is a housewife. Patient doesn’t
consume alcohol, smoke, and drug.

Family sickness history:

Patient doesn’t have family sickness history like cancer, asthma, etc.
Allergies :

Patient dosn’t have medicine alergy

Review of Systems:

Constitutional : Mrs.S, has been generally feeling well the last couple of weeks

Eyes : no changes in vision, double vision, blurry

vision, wears glasses

ENT : No congestion, changes in hearing, does

not wear hearing aids

Skin/Breast : no rashes

Cardiovascular :No SOB, chest pain, heart palpitations

Pulmonary : No cough

Endocrine : No changes in appetite

Gastro Intestinal : No n/v/d or constipation.

Genito Urinary : No increased frequency or pain on urination

Musculo Skeletal : no changes in strengths, no joint tenderness or swelling

Neurologic : No
changes in

Memory Psychology : No
changes in

Mood Heme/Lymph : No
problems

Physic control :

General conditions: good

Awareness : composmentis
a. Vitals:

Temp : 36

RR : 24 x /minute

Pulse : 80x/minute

BP : 100/70mmHg

HB : 9gr/dl

LILA : 26cm

Weight before pregnancy : 50 kg

Weight today : 55 kg

High : 160 cm

b. General and Obstetric

Mrs. S, sitting up in bed

Eyes : PERRLA, EOM intact, with pale conjungtiva

ENT : No congestion, changes in hearing, does

not wear hearing aids

Neck : No noticeable or palpable swelling, redness nor rash around

throat or on face

Lymph Nodes : No lymphadenopathy

Cardiovascular : RRR no m/r/g, no JVD, no carotid bruits

Lungs : Clear to auscltation, no use of acessory muscles, no

crackles or wheezes.

Skin : No rashes, skin warm and dry, no erythematous

areas

Breast : hyperpigmentation in areolla

Psychiatry :-
 Abdomen : There are no scars, the abdomen looks enlarged according the age of
gestational, with linea nigra.

Genito Urinary : Genital exam not performed since complaints not related.

Rectal : No symptoms indicated blood loss.

Extremeties : No edema, cyanosis or clubbing

Patella reflex : +/+

Musculo Skeletal : 5/5 strength, normal range of motion, no swollen

orerythematous joints.

Neurological : Neurological exam not performed since

complaints not related.

Assesment :

Anemia in pregnancy, if not treated properly can increase the risk of dangerous
complications, such as preterm labor. In addition, anemia can also increase the risk of low
birth weight in infants. On the maternal side, anemia can increase the risk of postpartum
depression and postpartum maternal mortality.

The cause of anemia truly comes down to how many red blood cells are being produced in
the body and how healthy they are. A fall in hemoglobin levels during pregnancy is caused
by a greater expansion of plasma volume compared with the increase in red cell volume. This
disproportion between the rates of increase for, plasma and erythrocytes has the most
distinction during the second trimester.

Dx : Mrs. S G1P0A0 18 weeks pregnancy with light anemia.

Ds : Mrs.S said this is her first pregnancy, and in the 18 weeks pregnancy she moans
often feel dizzy and weak.

Needs :

1. Explain to Mrs. S about her chief complaint

2. Recommend to Mrs. S to get enough sleep
3. give her any medicine like Fe and calc
 4. give information how to consume Fe

Plan :

1. Explain her about her moaning

Result : Mrs. S undestand
2. Recommend her to get enough sleep minimum 7-8 hours/day
Result: she understand and do the advice
3. Advice her to consume enough nutrition
Result: she understand
4. Give her Fe tablet
Result: she receive
5. Give information how to consume Fe tablet
Result: she understand
6. Advice her to follow up next month or if she has moaning.
Result: she understand