A.

Identity

Name : Mrs. DN
Age : 27 years old
Sex : Female
Medical record : 168437
Address : Intan Residence, D-15, Nongsa
Religion : Islam
Date of entry : January 10, 2017

Proxy : Mr. A
Age : 36 years old
Sex : Male
Address : Intan Residence, D-15, Nongsa
Religion : Islam
Occupation : Government Employee

B. Anamnesis
1. Chief complaint
Patient came with complaint thea was a roung of clear fluid from the vagina

2. History of present illness

Patients arrived from PONEK, with complaint thers was a mount of clear fluid
from the vagina at 3am (early morning). This patiens complaint about with labor,
there is bloody (-). The Fluid berwarna jernih dan tidak berbau, ibu tidak demam,
gerakan janin masih dirasakan oleh ibu sejak 2 hari yang lalu Riwayat
tekanan darah tinggi, jantung, asma dan diabetes mellitus disangkal oleh pasien.
Pasien menikah 1 kali selama 1 tahun. Riwayat pemakaian KB disangkal oleh
pasien. Riwayat alergi disangkal oleh pasien

3. Post illness history

- Hypertension (-)
- Asthma (-)
- Mellitus Diabetic (-)
- Allergies (-)
- Heart Disese (-)

4. Family illness history

- Hypertension (-)
- Asthma (-)
- Mellitus Diabetic (-)
- Heart Disese (-)

5. Menstruation history
- Menarch in 15 years old
- Menstruation cycle is 28-30 days
 - Duration as long as 3 days. Regular
- First day of last menstruation; April 05, 2017

6. Antenatal care history

Patient had ANC 7 times during pregnancy with doctors

7. Marriage history
Married , once for 1 years until now at 2016

8. Obstetric history
This is her 1 pragnancy and baby
- Sex: Female
- BW: 2948 gr
- BL: 49 cm

9. Contraception history
Never use contraception

10. Habbit history

- smoking (-)
- alcohol (-)
- drugs & herb (-)

C. physical examination
a. general status
- general condition : moderate
- sensorium : compos mentis
- weight : 59 kg
- height : 151 cm
- BMI : 25,87
vital sign : BP : 120/70 mmhg
HR : 80 x/i
RR : 20 x/i
T : 36,8 oC
- Head : normochepali
- Eye : conjungtiva anemis (+/+), sklera icteric (-/-)
- Neck : Normal
- Thorax : Pulmo : vesicular (+/+), ronchi wheezing (-/-)
Cor : regular
- Abdomen : arah memanjang, nigra linea (+), peristaltic (+)
Leopold examination
- Leopold I : Teraba bokong
- Leopold II. Teraba punggung sebelah kiri
- Leopold III. Teraba kepala
- Leopold IV. Belum masuk PAP
Pelvic examination
- Promontorium : Tidak teraba
 - Spina Isciadica: Agak menonjol
- Intertuberum Distance : 7 cm

D. Obstetric Status
Fundal Height : 30 cm
Leopold examination
- Leopold I : Teraba bokong
- Leopold II. Teraba punggung sebelah kiri
- Leopold III. Teraba kepala
- Leopold IV. Belum masuk PAP
Pelvic examination
- Promontorium : Tidak teraba
- Spina Isciadica: Agak menonjol
- Intertuberum Distance : 7 cm
Inspekulo : Tampak cairan keluar dari OUE dengan tes lakmus (-)
VT : P 2 cm, efficement 25%, ketuban (+)
Tidak teraba portio lunak, penurunan Hodge I
Tidak teraba bagian kecil/tali pusat.

E. Workup
Laboratory studies, January 10, 2017
HEMATOLOGI, KIMIA DARAH, IMUNOSEROLOGI
Result Reference value Satuan
Hb 8.3 11.0 16.5 gr/dl
Leukosit 11.300 3500 10.000 /ul
Ht 26 35 50 %
Eritrosit 3,8 3.8 - 5.8 juta/ul
Platelet 388 150 500 ribu/ul
MCV 69 80.0 - 97.0 fl
MCH 21.4 80.0 - 97.0 pg
MCHC 31 31.5 35.0 g/dl

F. Working diagnosis
G3P2A0H1 gestasional age 40-41 week + CPD + PPROM + Anemia moderate
(Hb : 8,3 gr/dl)

G. Working Management
- IUVD RL 30 gtt/i
- Ceftriaxone Inj. 1gr
- Dexamethasone Inj. 2 amp
 - Prepare CS Cito with dr.Ni Made Indri DS, Sp.OG

H. Report of cesarian section

- Do the aseptic and antiseptic
- Make a pfanenstiel incision (8cm) in length
- after opened the peritoneum, visible the front wall of the uterus
- the vesicouterina plica is cut cross wise
- make a concave in the lower segment of the uterus, dilated to left and right
- the baby delivered. BW : 1700 gr , BL : 44 cm
- deliver the placenta
- lower segment of the uterus is satured
- control the bleeding
- abdomen count satured loyer by loyer

I. Post operation diagnosis

P3A0H2 post CS with indication CPD + PPROM + Anemia moderate (Hb : 8,3 gr/dl)

J. Management post operation

- IUVD RL drip tramadol 28 gtt/i
- Ceftriaxone Inj. 2x1
- Metronidazole Inj. 3x1
- Ketorolac Inj. 2x1
- Pronalgess Supp 2x2
- Transfusion PRC 2 kolf

Follow up after operation

S:
O : - general condition : moderate
- sensorium : compos mentis
vital sign : BP : 130/70 mmhg
HR : 88 x/i
RR : 20 x/i
T : 36,7 oC
Fundal height : parallel with umbilical
A : P3A0H2 post cesarian section with indication previous cesarian section 2x + antepartum
haemorrahage (heavy, reccurance) e.c placenta previa + anemia moderate (hb: 8.6 gr/dl)

P : IUVD RL drip tramadol 28 gtt/i

- Ceftriaxone 2x1 gr
- Metronidazole 2x500mg
- Ketorolac 2x1 amp
- Transamin 3x1 amp
- Vik K 3x1 amp
- Vit C 3x1 amp
- Transfusion PRC 2 kolf