Night Shift Report 2410-2014

Aldo
Glenn
Sabrina

Identity
Name : Ny. O
Age: 24 y.o
Adress: Jalan Limo Tengah RT 04/03

Main symptoms
Wet pants since 1 days before admission (referred by
RSUD Depok because lack of NICU)

Riwayat Kehamilan
Pasien mengaku hamil sejak 8 bulan SMRS. HPHT:
11/3/2014. TP: 18/12/2014~ 32 minggu. Di RSIA Graha
Permai Ibu dilakukan USG 1x pada tanggal 13/10/14
diketahui bahwa usia usia kehamilan 29 minggu. (saat
ini 31-32 minggu). Saat itu dikabarkan kondisi janin
baik. Plasenta di bawah

Disease History
5 hours prior admission to the hospital, patient said that
there are water leakage in her vagina that she cannot
control. This water, previously appear 1 day before
admission when patient notice that her pant is wet.
Theres fever since 2 hours before admission. No
bleeding, vomiting, or vaginal discharge. No itch or
dental infection

Prior history of disease

Hypertension, DM, heart disease is denied

Menstruation HIstory
Menstruation cycle is 26 days, regular, length 5-7 days.
Number of napkins 2-3x/day, no pain

Marriage history
Married 1x

Obstetrical history
G1 this pregnancy

Contraception history
No prior history of contraception

Social History
Social condition of patient is well. Patients husband is
well-of
.

Physical Exam
Kesadaran: CM
Tanda Vital

BP: 130/80
Nadi: 102x/menit
Suhu: 37.9 derajat celcius
Pernafasan: 28x/menit

Physical Exam
IMT:
Tinggi badan: 157 cm
Berat badan : 68 kg
BMI: 27.6 (overweight)

Physical Exam
Normocephal
Eye: Conjungtiva is not anemic, sclera is not icteric
Chest: Simetrical in chest
Lung: Vesicular, wheezing (-/-_
Heart: S1, S2 (+), murmur (-) gallop (-)

Physical Exam
Abdomen :
Inspection: dull
Leopold exam

Physical Exam
Uterine fundus height: 26 cm
Head 5/5
No contraction
Fetal heart beat 162x/minute
Portio : smooth , valsava test positive, LEA +2, color:
green with thin consistency
Vaginal touche: Not done