NAMA : NURUL SUCI SOBARIYAH

KELAS : E
NPM : F622299
MATKUL : ENGLISH IN MIDWIFERY PRACTICE
DOSEN MATKUL : DHINI WAHYUNI NOVITASARI, S.S.T.,M.TR.KEB
TANGGAL : 25 FEBRUARI 2023

INTERVIEW!
Midwife : Good Morning Mrs Lutfi. I need to fill a medical report about your health status
Patient : Sure
Midwife : Your complete name ?
Patient : Lutfiah Aisyah
Midwife : What is your complete address?
Patient : I live in kp. Rancaekek Kulon Rt.01 rw.06 ds.rancaekek
Midwife : What made you come here?
Patient: I'm late for menstruation , Headache and feel nauseous
Midwife: Are you currently using contraception?
Patient: No, I haven't used contraception for the past 3 months
Midwife: Have you done a testpack?
Patient: not yet
Midwife : OK, thank you Mrs. Lutfiah for the information. I will do a pregnancy check with a
testpack first.

MEDICAL RECORD
Filled in by the Registration Officer on Date: 25 februari 2023 Time : 08.00 wib
No.RM : 025022023
Name/surname : Lutfiah Aisyah
No. NIK : 11111111111111
Status in Family : Wife
Age : 29 years
Address : kp. Rancaekek Kulon Rt.01 rw.06 ds.rancaekek
Gender : Female
Religion : Islam
Education : Senior High School
marital status : married
Phone : 08988888996
Financing Status : General

PATIENT IDENTITY
SUBJECTIVE DATA
Main Complaint :
patient complains late for menstruation , Headache and feel nauseous
 Menstrual History
 Age of menarche : 13th
 Last menstruation : 25–12-2022
 history of pregnancy and childbirth
 G2P1A0
 Family planning history
injection 3 months

OBJECTIVE DATA
general condition: good
physical examination :
Td : 120/80 mMhg
BB : 52 kg
Testpack : + positive
Stomach : ballatement

DIAGNOSIS
G2P1A0 gravida 8 week

THERAPY
Asam folat 1x1
Calcium 1x1
B6 2x 1