CASE

G5P4A0 43 years old, gestational age 37-38 weeks according to USG, alive single
intrauterine fetus, head presentation pro sectio caesarean as indicated high risk
pregnancy and sterile

I. IDENTITY
Name : Mrs. H
Age : 43 years old
Ethnicity : Javanese
Religion : Moslem
Occupation : Housewife
Education : Elementary school
Date of admission : 27th September 2017

II. HISTORY
Chief complaint:
Patient came to Atma Jaya hospital to do sectio caesarea and sterile as indicated
high risk pregnancy

History of present illness:

Patient came to Atma Jaya hospital to do sectio caesarea and sterile. Abdominal
pain is denied. Fever complaint, vaginal discharge, headache and blurred vision
was also denied.

History of past ilness:

o History of hypertension : denied
o History of diabetes mellitus : denied
o History of allergy : denied
o History of trauma : denied
o History of surgery : Subtotal thyroidectomy
as indicated struma nodusa in 2015
o History of asthma : denied
Family history:
o History of hypertension : hypertension at parents
 o History of diabetes mellitus : denied
o History of allergy : denied

History of menstrual cycle:

o Menarche : 12 years old
o Menstrual cycle : 30 days, regularly, with duration of 7 days,
changed 3 pads a day (about 60 cc), dysmenorrhea (-)
o First day of last menstrual period: January 2017

Marital history:
Married once, 23 years with his husband.

Contraception history:
The patient never use the contraception

History of antenatal care:

Patient has routine antenatal care with 7 visits at nearby clinics during this
pregnancy.

Obstetric history:
No Years Gestational Labor History Sex Birth Breast
Age Weight Feeding

1. 1995 9 months Spontaneous Male 2,100 < 6

pervaginam grams months

2. 1998 9 months Spontaneous Male 2,200 6 months

pervaginam grams

3 2006 9 months Vacum Female 3,100 6 months

grams

4 2010 9 months Vacum Female 3200 <6 months

grams
III. PHYSICAL EXAMINATION
General condition : appeared mildly ill
Level of consciousness : compos mentis
Vital signs:
o Blood pressure : 110/70 mmHg
o Heart rate : 76 beats per minute
o Respiratory rate : 24 breaths per minute
o Body temperature : 37,0oC
Height : 142 cm
Weight : 42,5 kg
BMI : 21,07 kg/m2

General Examination:
Eyes : anemic conjunctiva -/-, icteric sclera -/-
Mouth : wet oral mucosal membrane
Thorax :
o Heart : regular 1st and 2nd heart sounds, gallop (-), murmur (-)
o Lung : vesicular breath sounds +/+, rhonki -/-, wheezing -/-
o Mammae : areola hyperpigmentation +/+, nipple retraction -/-,
breast milk -/-
Abdomen :
o Inspection : convex, striae gravidarum (+)
o Palpation : supple, tenderness (-)
o Auscultation : bowel sounds (+), 8 times per minute
Extremities : edema (-/-/-/-), CRT <2 seconds, physiologic reflex (+/+/+/+),
pathologic reflex (-/-/-/-)

Puerperium Examination:
Fundal Height Measurement : 2 finger below the umbilical
Lochia: rubra 25 cc
Contraction: moderate
Mobilization: walking
IV. LABORATORY EXAMINATION (27/7/2017)
Examination Results Unit

Hemoglobin 13,3 g/dL

Hematocrit 39 %

Trombocyte 321 ribu/uL

Leucocyte 8,7 ribu/uL

Eritrocyte 4.27 juta/uL

MCV 72.2 fL

MCH 24.6 pg

MCHC 34.1 g/dL

Qualitative HBsAg negative

V. WORKING DIAGNOSIS
G5P4A0, 43 years old, gravid 37-38 weeks according to USG, Intrauterine Fetus,
head presentation pro sectio caesarean as indicated high risk pregnancy and sterile

VI. PLANNING
Sectio caesarea and sterile

VII. FINAL DIAGNOSIS

Mother : P3A0, 43 years old, post partus maturus with caesarean
section as indicated high risk pregnancy and sterile.
Baby : Term male neonate, 37-38 weeks of gestational age according
to New Ballard Score, birth weight 2,430 gram, birth length 44 cm,
APGAR score 8/9. Diagnosed as well baby

VIII. TREATMENT
Post Operative treatment :
- IVFD D10% : RL 2 : 1 1500 cc/24 hours
- Cefotaxime 3 x 1 gr IV
- Primperan 10 mg IV
IX. TAKE HOME MEDICINE
Amoxicilin 3 x 500 mg PO
Metronidazole 3 x 500 mg PO
Dysfatyl 3 x 1 tab PO
Sangobion 1 x 1 PO
 CASE 2

G2P1A0, 29 years old, 39-40 weeks of gestation according to first day of last
menstruation, alive single intrauterine fetus, head presentation pro sectio caesarea as
indicated with cephalopelvic disproportion and history of prior cesarean section

Name : Mrs. R
Sex : Female
Age : 29 years old
Address : Rawa Bebek
Ethnicity : Sundanese
Religion : Moslem
Occupation : Housewife
Education : Junior high school
Date of admission : 29 September 2017

I. HISTORY
Chief Complaint
Patient came to Atma Jaya hospital to have an elevtive sectio caesarean procedure as
indicated with cephalopelvic disproportion. Patient denied any fever, nausea and
vomiting, headache. Patient also denied any bleeding from her vagina, abdominal pain
and no any water flowed from her vagina throughout this pregnancy.

History of Present Illness

Patient came to the policlinic in Atma Jaya hospital with gestational age of 39-40 weeks
according to first day of last menstrual period to control her pregnancy. Patient denied
any fever, nausea and vomiting, headache. Patient also denied any bleeding from her
vagina, abdominal pain and no any water flowed from her vagina throughout this
pregnancy.

History of Past Illness

History of hypertension : Denied
History of diabetes mellitus : Denied
 History of allergy : Denied
History of asthma : Denied
History of trauma : Denied
History of surgery : Denied

Family History
History of hypertension : Denied
History of diabetes mellitus : Denied
History of allergy : Denied

History of Menstrual Cycle

Menarche : 15 years old
Menstrual cycle : 30/31 days, not regular, duration of 8 days, 4-5 pads a
day ( 80-100 cc), dysmenorrhea (-)

Marital History
Married once, its been 6 years with this husband.

Contraception History
Contraceptive implant for 3 years (2008 2011)
3-monthly contraceptive injection for 1 year (2012)
1-monthly contraceptive injection for 3 years (2013 2016)

History of Antenatal Care

Patient has a routine antenatal care with 6 visits at community health center and 3 visits
at Atma Jaya hospital.

Obstetric History
G2P1A0
First day of last menstrual cycle : 27th December 2016
Estimated due date : 3rd September 2017
No Husband Year Age of Mode of Complications Sex Current Birth Breastfed
no - Gestation Delivery Age Weight
1 1 2011 37 weeks Sectio CPD male 6 years 2300 +
caesarean old grams
 2 1 Current
pregnancy

II. PHYSICAL EXAMINATION

General condition : Appeared mildly ill
Level of consciousness : Compos mentis

Vital signs

Blood pressure : 110/70 mmHg

Heart rate : 84 beats per minutes
Respiratory rate : 20 breaths per minutes
Body temperature : 36.5o C
Nutritional status

Current weight : 40,5 kg

Height : 135 cm
BMI : 22,2 kg/m2

General Examination
Head : Normocephalic, deformity (-)
Eyes : Anemic conjunctiva (-/-), icteric sclera (-/-)
Nose and ear : Discharge (-), deformity (-)
Mouth : Wet oral mucosal membrane
Thorax
Heart : Regular 1st and 2nd heart sounds, gallop (-), murmur (-)
Lung : Vesicular breath sounds (+/+), rhonchi (-/-), wheezing (-/-)
Mammae : Areolar hyperpigmentation (+/+), nipple retraction (-/-), breast
milk (-/-)
Abdomen
Inspection : Convex, striae gravidarum (+), linea nigra (+)
Auscultation : Bowel sounds (+), 6 times per minute.
Palpation : Supple, tenderness (-)
Extremities : Edema (-/-/-/-), CRT < 2 seconds
Physiologic reflex (+/+/+/+), pathologic reflex (-/-/-/-)
Obstetric Examination
Fundal height : 32 cm
Estimated fetal weight : 2945 gram
Fetal heart rate : 140 bpm
Leopold maneuver
o Leopold I : Buttock
o Leopold II : Back on the right side
o Leopold III : Head
o Leopold IV : Convergent
Inspeculo : Not performed
Vaginal toucher : Not performed
Rectal toucher : Not performed

Cardiotocography

Baseline : 135 bpm

Variability : moderate
Acceleration : 3 times
Decceleration : -
 Fetal movement : 3 times
His :-
Intepretation : NST reactive

LABORATORY EXAMINATION

Types Results Units Normal Value

Hematology

Hemoglobin 11.3 g/dL 12.0 15.8

Hematocrit 34 % 36 48
Leucocytes 7,9 103/L 3.54 9.06
Trombocytes 298 103/L 200-400
Erythrocyte 4.28 103/L 4.0 5.2
MCV 81.3 103/L 79 93.3
MCH 27.1 106/ L 26.7 31.9
MCHC 33.3 fL 32.3 35.9
Blood Type B/ Rh (+) pg
BT / CT 2/4 g/dL minutes

1-2 3-6

Serology

HBsAg (-) Negative

III. WORKING DIAGNOSIS

G2P1A0, 29 years old, 39-40 weeks of gestation according to first day of last
menstruation, alive single intrauterine fetus, pro sectio caesarea as indicated head
presentation with cephalopelvic disproportion and history of prior cesarean section
 FINAL DIAGNOSIS
Mother : G2P1A0, 29 years old, post sectio caesarean as indicated cephalopelvic
disproportion and history of prior cesarean section
Baby : Term female neonate, appropriate for gestational age, 38 weeks of gestational
age according to New Ballard Score, birth weight 2,710 gram, birth length 46 cm, head
circumference 33 cm, APGAR 7/ 9. Diagnosed as healthy neonate

IV. PLANNING
Pre Operation :
Pro cesarean sectio the next following day
Cefotaxim pre operation 1 gr IV

Post Operation :
Cefotaxime 2x1 gram IV
RLD5 : NaCL 2 : 1
Tranexamat acid 3 x 500 mg IV
Tramadol 3 x 100 mg / kolf
Kaltrofen 3 x 2 supp
Ranitidin 2 x 50 mg IV
Oxytocin 3 x 10 IU drip
Hb routine test 6 hours post operation
Check urine output every 4 hours

Treatment in ward :
Cefotaxime 2 x 1 gr IV
Primperan 10 mg IV
Tranexamat acid 3 x 500 mg IV
Tramadol 100 mg 3x drip
Oxytocin 3 x 10 IU drip

V. TAKE HOME MEDICINE

Cefadroxil 3 x 500 mg PO
Mefenamat acid 3 x 500 mg PO
Moloco B12 3x1 tab
Sangobion 1 x 1 tab
Paracetamol 3 x 500 mg
 CASE 3

G1P1A0, 21 years old, 40 weeks of gestation age according to first day of last
menstruation cycle, alive single intrauterine fetus

Name : Mrs. DR
Sex : Female
Age : 21 years old
Address : South Jakarta
Ethnicity : Javanese
Religion : Moslem
Occupation : Housewife
Education : Elementary school
Date of admission : 28 September 2017

VI. HISTORY
Chief Complaint
Patient feels abdominal pain and mucoid vaginal discharge since 8 hours before
admission.

History of Present Illness

Patient came to the emergency room in Atma Jaya hospital with abdominal pain and
mucoid vaginal discharge and the pain is progressively worse. The pain was felt at all
of the abdomen regio. The discharge is clear, covered in blood and didnt have any
odor.

History of Past Illness

History of hypertension : Denied
History of diabetes mellitus : Denied
History of allergy : Denied
History of asthma : Denied
History of trauma : Denied
History of surgery : Denied
 Family History
History of hypertension : Denied
History of diabetes mellitus : Denied
History of allergy : Denied

History of Menstrual Cycle

Menarche : 13 years old
Menstrual cycle : 28 days, regular, duration 5 days, 3 pads a day ( 60 cc),
dysmenorrhea (-)

Marital History
Married once, its been 1 years with this husband.

Contraception History
No history of contraception usage

History of Antenatal Care

Patient didnt have a routine antenatal care visit throughout her pregnancy ( 1 times at
community healthcare center )

Obstetric History
G1P0A0
First day of last menstrual cycle : 18th December 2016
Estimated due date : 25th September 2017
No Husband Year Age of Mode of Complications Sex Current Birth Breastfed
no - Gestation Delivery Age Weight
1 1 Current
pregnancy

VII. PHYSICAL EXAMINATION

General condition : Appeared moderately ill
Level of consciousness : Compos mentis

Vital signs

Blood pressure : 90/60 mmHg

 Heart rate : 96 beats per minutes
Respiratory rate : 24 breaths per minutes
Body temperature : 36.5o C
Nutritional status

Current weight : 83 kg
Height : 160 cm
BMI : 32,4 kg/m2

General Examination
Head : Normocephalic, deformity (-)
Eyes : Anemic conjunctiva (-/-), icteric sclera (-/-)
Nose and ear : Discharge (-), deformity (-)
Mouth : Wet oral mucosal membrane
Thorax
Heart : Regular 1st and 2nd heart sounds, gallop (-), murmur (-)
Lung : Vesicular breath sounds (+/+), rhonchi (-/-), wheezing (-/-)
Mammae : Areolar hyperpigmentation (+/+), nipple retraction (-/-), breast
milk (-/-)
Abdomen
Inspection : Convex, striae gravidarum (+), linea nigra (+)
Auscultation : Bowel sounds (+), 6 times per minute.
Palpation : Supple, tenderness (-)
Extremities : Edema (-/-/-/-), CRT < 2 seconds
Physiologic reflex (+/+/+/+), pathologic reflex (-/-/-/-)

Obstetric Examination
Fundal height : 28 cm
Estimated fetal weight : 2635 gram
Fetal heart rate : 130 bpm
Leopold maneuver
o Leopold I : Buttock
o Leopold II : Back on the left side
o Leopold III : Head
 o Leopold IV : divergent
o His : 35 minutes, 4x / 10 minutes, Moderate-High Intensity
Inspeculo : Not performed
Vaginal toucher : Pain (-), Dilatation 10 cm, 100%, Membrane intact (+)
Head presentation, Hodge +3
Rectal toucher : Not performed

LABORATORY EXAMINATION

Types Results Units Normal Value

Hematology

Hemoglobin 12.3 g/dL 12.0 15.8

Hematocrit 37 % 36 48
Leucocytes 22,9 103/L 3.54 9.06
Trombocytes 323 103/L 200-400
Erythrocyte 4,55 103/L 4.0 5.2
MCV 80,3 106/ L 79 93.3
MCH 27 fL 26.7 31.9
MCHC 33,6 pg 32.3 35.9
Blood Type O/ Rh (+) g/dL

Serology

HBsAg (-) Negative

Anti HIV (-) Negative

VIII. WORKING DIAGNOSIS

G1P1A0, 21 years old, 40 weeks of gestation age according to first day of last
menstruation cycle, alive single intrauterine fetus
 FINAL DIAGNOSIS
Mother : P1A0, 21 years old, post partus matorus spontaneously
Neonatus assesment : Term male neonate, appropriate for gestational age, 38-39 weeks
of gestational age according to New Ballard Score, birth weight 2800 gram, birth length
46 cm, APGAR 8/ 9, suspect sepsis neonatorum

IX. PLANNING
Treatment in ward :
Amoxcilin 3 x 500 mg PO
Methergin 3 x 0,125 mg PO
Sangobion 1 x 1 tab

X. TAKE HOME MEDICINE

Amoxicilin 3 x 500 mg PO
Methergin 3 x 0,125 mg PO
Sangobion 1x1 tab