Case

• Name : Mrs. N
• Age : 31 yo
• Address : Pujuk
• Admitted : 25 April 2017
• RM : 13 73 24
TIME SUBJECTIVE OBJECTIVE ASSESSMENT PLANNING

15/07/ Patient come alone to NTB GH with General status G2P1A0L0 34-35 DM planning:
2016 G2P1A0L0 34-35 weeks S/L/IU GC: well weeks S/L/IU head Diagnostic:
11.30 head presentation with laten phase GCS : E4V5M6 presentation with • Check CBC,
with gastroskisis. Patient pregnant 8 BP : 110/70 mmHg laten phase with HbsAg
month, confessed abdominal pain HR: 76 tpm gastroskisis.
since 02:00 am, bloody slime (-), RR: 20 tpm Therapy:
water leaked out (-), fetal movement Tax: 36.6◦ C • Pro termination
(+). with C section
Local status
History of DM (-), HT (-), asthma (-), Eye : an (-/-), ict (-/-) DM co to GP, GP co
allergic (-), other chronic disease (-) Pulmo ves (+/+), rh (-/-), wh (-/-) to Spv (at 14.00),
History DM in family (+), HT (+), Cor : S1S2 single regular, murmur (waiting for
asthma (-), allergic (-) (-), gallop(-) laboratory result
Abdomen: before
LMP: 29-08-2016 Scar (-), striae gravidarum (+), consultation)
EDD: 24-7-2016 linea nigra (+) advice:
GW : 38-39 weeks Extremity: oedema (-/-) warm - The spv will repeat
(+/+) the USG
History of ANC: 3x at PHC and 1x at
NTB GH Obs status:
Last ANC: 15/04/2017 L1 : breech
Result : BP 110/70 mmHg, GW 31- L2 : back to the right side
32 weeks, BW 60 kg L3 : head
L4: 5/5
History of USG: 1x at Sp.OG UFH: 23 cm
History of family planning: - EFW : 1705 g
Next family planning: - FHB : 12-12-12 (144 bpm)
UC : 1x10’ 15”
Obstetrical history:
1. Aterm/female/midwife/ 3100 VT : Ø 1 cm, eff 10%, amnion
g/Spt-B/ 8 y.o/ L (+), head palpable, HI, denom
unclear, not palpable small part &
umbilical cord
TIME SUBJECTIVE OBJECTIVE ASSESSMENT PLANNING

Laboratory exam (25/04/2017):

HGB: 9,4
RBC: 3,85
HCT: 29,0
MCV: 75,3
MCH: 24,4
MCHC: 32,4
WBC: 16,26
PLT: 308
GDS : 100
HbsAg : non reactive
TIME SUBJECTIVE OBJECTIVE ASSESSMENT PLANNING
14.00 Fetal movement (-), abdominal pain (-) General status DM co to GP, GP co
GC: well to Spv (at 14.00),
GCS : E4V5M6 (waiting for
BP : 120/80 mmHg laboratory result
HR: 88 tpm before
RR: 18 tpm consultation)
Tax: 37.0◦ C advice:
- The spv will came
UC : (-) to hospital and
DJJ : 8-8-9 repeat the USG

15.00 Fetal movement (-), abdominal pain (-) General status G2P1A0L1 39-40 Spv advice :
GC: well weeks, IUFD with Pro C-section
GCS : E4V5M6 Susp congenital tomorrow morning
BP : 120/80 mmHg anomaly + at 08.00
HR: 88 tpm macrosomia
RR: 18 tpm
Tax: 37.0◦ C

UC : (-)
DJJ : (-)

USG by Spv : FHB (-)

BPD : 37/38