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Case No. 41
PATIENTS ID
Name
: Mrs. A
Age
: 33 years old
Address
: Tunggul Hitam
MR No.
: 84 11 41
Admission date : September 8th, 2013
ANAMNESIS
A 32 years old patient admitted to General
Hospital of Dr. M. Djamil Padang on
September 8th, 2013 at 11:30 am, with chief
complain fluid leakage from the vagina since
11 hours ago
PHYSICAL EXAMINATION
GA Cons BP
PR RR T
Mdt CMC 120/80
80x 20x 37
Body Height
: 150 cm
Present Body weght
: 60 kg
Before Pregnancy Body Weight
: 50 kg
BMI
: 22.2 kg/m2
Upper Arm Circumferrence
: 24 cm
PHYSICAL EXAMINATION
Eyes : Conjunctiva wasnt anemic, Sclera wasnt icteric
Neck : JVP 5-2 cmH2O,
thyroid gland no enlargement
Chest
Abdomen
: H/L normal
Genitalia
Extremity
: OR (obstetric record)
: OR (obstetric record)
: Edema -/-,
Abdomen
Inspection : enlarged due to a term pregnancy, median line
hyperpigmentation, cicatrix (+) previous CS with pfannenstiel
incision
Palpation :
L1 : uterine fundal was palpated 3 fingers below proccesus xyphoideus,
a soft, large noduler mass was palpated
L2 : hard and resistance structure was felt on the left side,
numerous small and irregular structures were felt in the right side
L3 : a hard round mass was palpated, fixated
L4 : convergen
Uterine fundal height : 38 cm, EBW : 3875 g, uterine contraction : (-)
Percussion : tympani
Auscultation : normal peristaltic sound,
FHR : 140-152 bpm
Pelvic Inlet
Promontory couldnt be reached
Inominate line was palpable 1/3 1/3
Sacrum bone concave
Pelvic side wall straight
Ischiadic spine not protruded
Coccygeus bone moveable
Arc of pubic > 90
Pelvic Outlet
Inter tuberous distance could be passed through by normal adult fist
(>10.5 cm)
ULTRASOUND
ULTRASOUND
Fetal alive, singleton, intrauterine, head presentation
Fetal movement was limited
Biometrics :
BPD
: 94.8 mm
AC
: 349 mm
FL
: 78.0 mm
EFW
: 3714 gr
CARDIOGRAPH
CARDIOGRAPH
Interpretation :
Baseline
: 145 bpm
Variability
: 5-15 bpm
Acceleration
: (+)
Deseleration
: (-)
Contraction
: (-)
LABORATORY FINDING
Laboratory finding
12,5 gr/dl
9,5-15,0
Leucocyte
19.500/mm3
5.916.9
Hematocrit
38 %
28.040.0
Trombocyte
193.000/mm3
146429
10,5
10,0-13,6
29
29,2-39,4
PT
APTT
URINALYSIS
Protein
Glucose
Leukocytes
Erythrocyte
Cylinder
Crystal
Epithelial
Bilirubin
Urobilinogen
: (+)
: (-)
: 1-2
: 0-1
: (-)
: (-)
: (+) flat
: (-)
: (+)
Diagnosis :
G2P1A0L1 term pregnancy + Previous CS + PROM
Fetal alive, singleton, intra uterine, head presentation, H I
Management :
Control GA, VS, FHS, uterine contraction.
Routine blood examination
Antibiotic skin test
Informed consent
Consult to an anesthesiologist
Report to Operating theatre
Planning : Caesarean Section
THANK YOU