Identity
Name
: Mrs. S
Age
: 33 years old
Ethnic
: Betawi
Religion
: Moslem
Occupation
: Housewife
Education
: Primary School
Date of admission
: June 8th 2015
at 13.05
Anamnesis
Chief complaint
of
of
of
of
of
of
denied
History of
History of
History of
Antenatal
doctor)
hypertension
: denied
diabetes mellitus : denied
allergy : denied
epilepsy
: denied
hematologic disease : denied
urinary tract/kidney disease
:
trauma : denied
surgery : denied
cronic infection : denied
Care
: twice (midwife and
Physical examination
General condition
: calm
Level of consciousness
mentis
Vital Signs
: compos
: 120/70 mmHg
Blood pressure
: 80x/minutes
Heart rate
Respiration rate
: 20x/minutes
Temperature : 36,5o C
Body
General examination
Eyes
: anemic conjunctiva
-/-,
icteric sclera -/Mouth : wet oral mucous
membrane
Thorax
Heart : regular 1st and 2nd heart sounds,
murmur - , gallop
Lung : vesicular breath sounds +/+,
rhonchi -/-,
wheezing -/ Mammae : areola hyperpigmentation +/+,
nipple retraction -/-, breast milk -/-
Abdomen
Extremities
: edema -/-, CRT < 2s
physiologic reflex (+/+/+/+),
pathologic reflexes (-)
Gynecologic examination
First
Laboratory examination
Blood Examination
Hemoglobin
Hematocrit
Leucocyte
Trombocyte
Blood type
HbsAg
:
:
:
:
:
: 11,1 g/dl
32%
5.400/uL
197.000/uL
O+
-
Laboratory examination
Urine Analysis
Glucose
: Protein : Bilirubine
: Urobilinogen : pH
:7.5
Density:1015
Occult blood : +
(one)
Ketone : Nitrite :-
Leucocyte
(three)
Sediment
:+++
Leucocyte
Eritrocyte
Epithelial
Cylinder
Crystal : Bacteria
Others :-
:18-20
:1-2
:+
::-
Working diagnosis
G4P3, 33 years old, 7-8 weeks gravid according
to first day of last menstrual period with
hiperemesis gravidarum and urinary tract
infection
Planning
1.Cefotaxime 3x1g IV
2.Primperan 3x1 ampoules drip IV
3.Neurobion 1 ampoules drip IV
4.Ranitidin 2x1 ampoules drip IV
5.IVF Futrolit 1500cc/24 hours
FOLLOW UP
Date
9th of
June
2015
05.00
am
Subjective
Objective
Nausea
General
(-),
: moderately ill
Vomiting condition
(-),
headache Level of
(+)
: Compos
consciousn
defecation
mentis
ess
(-), void
(+),
complains Vital signs
felt better
than
o Blood
: 110/70
yesterday.
pressure
mmHg
o Heart
: 90x/minutes
rate
o
:
Respiratory 23x/minute
rate
s
o Body
temperatur : 36.7C
e
Physical
Palpable
Examinatio hepatomeg
n
aly
Assesment
Planning
G4P3, 33 years 1. Repeat urine
analysis 24 hour
old, 7-8
after antibiotics
weeks gravid given
according to
2. Cefotaxime 3x1g
first day of
last menstrual IV
period with
4.Neurobion 1
hiperemesis ampoules drip IV
gravidarum
and urinary
5. Ranitidin 2x1
tract infection ampoules drip IV
6. IVF Futrolit
1500cc/24 hours
7.Primperan 3x1
ampoules drip IV
Date
10th of
June
2015
05.00
am
Subjective
Objective
Nausea General
: calm
(-),
condition
Vomiting
(-),
Level of
headach consciousn : Compos
mentis
e (-)
ess
defecatio
n (+),
void (+) Vital signs
o Blood
: 110/60
pressure
mmHg
o Heart
: 64x/minutes
rate
o
:
Respiratory
20x/minutes
rate
o Body
temperatur : 36.3C
e
Physical
Palpable
Examinatio hepatomeg
n
aly
Assesment
Planning
G4P3, 33 years
old, 7-8
- Patient Discharged
weeks gravid
->
according to Cefotaxime
Cefadroxi l3x500mg
first day of
last menstrual po
period with
Primperan IV ->
hiperemesis 3x10mg po
gravidarum
and urinary
Stop ranitidine
tract infection
Stop Neurobion
Aff IVF
Control in 1 week
Laboratory examination
(10 June 2015)
Urine Analysis
Glucose : Protein : Bilirubine
: Urobilinogen : (+)
pH
:8.5
Density : <1005
Occult blood : +
(one)
Ketone : Nitrite :-
Leucocyte
Sediment
Leucocyte
Eritrocyte
Epithelial
:+
Cylinder
Crystal
Bacteria
Others
:(-)
: 3-5
:1-2
::::-
Final
Diagnosis
33 years old, 7-8 weeks gravid
G4P3A0,
according to first day of last menstrual
period with hiperemesis gravidarum
and urinary tract infection