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Mrs. April, 28-year-old, G1P0, 37 weeks pregnancy was brought to the ER with a chief
complain watery discharge from the vagina since one day ago. She admitted that she
had abdominal pain/cramp for several hours and she felt the baby was still moving.
1. Identify the patient problem? Keluarnya cairan dari vagina dan nyeri/kram di
bawah perut
2. Generate a list of hypothesis for each problem?
Keluarnya cairan: Pecah ketuban, air kencing, infeksi yaitu keputihan
Nyeri perut: His, infeksi urinaria, trauma
3. What further information do you need? Anamnesis cairannya sejak kapan,
warnanya apa dan anamnesis nyeri perut sakitnya terus menerus (infeksi)/ hilang
pergi,
Catatan:
- Akibat stress dapat membuat spincter ureta melemah sehingga banyak kencing
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Previous medical history:
Three days ago she had experienced some frequent, urging (mendesak) and painful
voiding. She also had yellowish discharge from vagina. She went to see the physician
and diagnosed as Urinary Tract Infection with leukorhoe (keputihan) ec (et causa)
bacterial infection. The urine culture was found Gram positive bacteria. The doctor
prescribed paracetamol tablet 500 mg, ten tablets and Cefadroxil tablet 500 mg, two
times a day, for a week, but she didn’t took the medicine because affraid it would
interfere with the fetus.
1. Identify the patient problems? Keputihan berwarna kekuningan
2. Do you change your hypothesis?
Keluarnya cairan: Pecah ketuban, air kencing, infeksi yaitu keputihan
Nyeri perut: His, infeksi urinaria
3. Give comment for the treatment given for the patient. Describe the
prescription? Apabila infeksi tidak perlu diberikan parasetamol sebab tidak terlalu
berpengaruh dan malah merugikan karena tidak bisa monitor kemajuan/ kesuksesan
dari antibiotic. Pemberian antibiotic cefadroxil tidak tepat
Catatan:
- Pada ibu hamil peluang infeksi tinggi sebab air ketuban basa ada lactobacillus
- Keputihan berwarna putih karena jamur, abu-abu karena parasite

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 - Keputihan, nyeri kencing, his bisa terjadi bersamaan

dr.Cita Citata
SIP:000/0000-Dinkes/29-SIP-11-DUM/11
Jl. Disini 35-bandung
--------------------------------------------------
Bandung, 17 Maret 2016

R/ Cefadroxil 500 mg cap no XXI

S 3 dd cap I pc
nad
R/ Paracetamol 500 mg tab no X
S 3 dd tab 1 pc
Nad
---------------------------------------------------
Name : Ny. Ayu Tingting
Age : 28 thn
Address : jl. G. Mujaer
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Physical Examination reveals:

Temperature is 37.1 oC (N), BP: 110/70 mmHg (N), HR: 92 bpm (N), RR: 24 x/m (N).
Head and neck are within normal limits
Lung and heart are normal.
Suprapubic tenderness: (-)
Costovertebral (nyeri di ventebra) angle tenderness: (-) (artinya

Obstetric examination:
External examination:
Fundal height : 34 cm above symphysis
Leopold maneuver : head above symphisis, 2/5, back on the right,
Fetal heart rate : 156 bpm regular
Uterine contraction : twice every 10 minutes regular, 25 seconds, weak.

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Vaginal examination
Speculum examination
Vulva/vagina
Portio
Cervical dilatation
Amniotic membrane
Presenting part
: water leaking from external uterine ostium
Lakmus test (+) (diatas 7 artinya basa)
: no abnormalities
: axial position, soft, effacement 50%
: 1 - 2 cm
: negative, clear watery discharge
: head left occiput anterior (harusnya melintang), station
0

1. What are the patient problem? Pada pemeriksaan speculum ada kebocoran,
lakmus positif, ada his, pembukaan dan penipisan
2. What is your conclusion? G1P0A0 37 minggu tunggal hidup inpartu kala 1 fase
laten
3. What more information do you need?
Catatan:
- 140/90 perlu diperhatikan hipertensi
- Pemeriksaan kepala dari Leopold (kepala diatas simfisis) dan PP
- KPP (ketuban pecah premature) adalah ketuban pecah sebelum waktunya yaitu > 1
jam sebelum kelahiran. Karena pada pasien ini sudah inpartu maka hanya
diberikan ‘riwayat KPP’ dan harus dituliskan
- KPP bisa bahaya hipoksia takutnya kepala bayi menekan tali pusat dan infeksi
karena vagina tidak steril
- Planning diagnose (pemeriksaan laboratorium), planning terapi, planning follow
up
___________________________________________________________________
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Laboratory Examination
Hb : 12.9 gr/dl
Leucocyte : 10.000 /mm3
Platelet count : 200.000/mm3
Urine : leucocyte : much, bacteria (+)
Gram staining : Gram positif coccus bacteria
Nitrazin test : Positif

1. Identify the problem?

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2. What is your diagnosis,what are your reason ? Infeksi saluran kencing karena
bakterinya banyak dan pewarnaan gram positif
3. What are your management plans for this patient? Pemerian antibiotik

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The Diagnosis is premature rupture of the membrane due to infection
The doctor in charged gives Mrs. April, ampicillin antibiotics IV, and plans to have
labor augmentation.
1. Why the doctor diagnosis PROM? Explain.
2. Why the doctor choose ampicillin? Explain.

Page 6/ Epilogue
Six hours later female baby is born spontaneously, birth weight 2600 g, length 48 cm.
The newborn examination is in normal condition