CASE 1:

G3P2A0, 43 yo, 36-37 weeks gestation according to first day of last menstrual period,with
active phase one, single live fetus, intrauterine, stage 1 active phase, breech presentation
Identity

Name
Age
Ethnicity
Religion
Occupation
Education
Date of admission

: Mrs. W
: 43 years old
: Javanese
: Moslem
: House wife
: Elementary school
: November 25th 2014

Anamnesis
Chief complaint:
Abdominal discomfort 4 hours before hospital admission.
History of present illness:
Patien complaint abdominal discomfort 4 hours before hospital admission. Patient also
complaint watery vaginal discharge which came out from her genital. History of trauma is denied.
History of coitus was 1 week before the complaint was made.
History of past illness:

History of hypertension
History of diabetus melitus
History of allergy
History of asthma
History of trauma
History of previous operation

: Denied.
: Denied.
: Denied.
: Denied.
: Denied.
: Denied.

History of menstrual cycle:

Menarche
Menstrual cycle

: 17 years old.
: 30 days, regularly, with a duration of 5
days, changed 3 pads a day. No

First day of last menstrual cycle

dysmenorrhea
: March 17th 2014.

Antenatal care:
History of antenatal care: 7 times at local clinic

 Obstetric history:
Married 1 times, already 25 years with the last husband.

No.

Date

1.

1991

2.

From

Gestational

husband1

Age
9 months

1995

9 months

Birth

Labor History

Sex

Spontaneous

Male

Weight
3000 gr

Vaginal Delivery
Spontaneous

female

3000 gr

Vaginal Delivery

Physical examination
General condition
Conciousness
Vital signs
:
Blood pressure
Heart rate
Respiratory rate
Body temperature
Weight
Height

: Appeared moderately ill.

: Compos mentis.
: 120/90 mmHg.
: 90 bpm.
: 24 bpm.
: 36,7C.
: 63,5 Kg.
: 151 cm.

General examination
Eyes
: anemic conjunctiva -/-, icteric sclera -/-.
Mouth
: wet oral mucous membrane.
Thorax
:
Heart
: regular 1st and 2nd heart sound, murmur (-), gallop (-).
Lung
: vesicular breath sounds +/+, ronchi (-/-), wheezing (-/-).
Breasts
: areola hyper pigmentation +/+, nipple retraction -/-,breast milk (-).
Abdomen
:
Inspection
: convex, linea nigra (+), striae gravidarum (+).
Auscultation : bowel sounds (+), 3 times per minute.
Palpation
: supple, pain on palpation (-).
Extremities
:
Edema -/-, CRT < 2 seconds
Physiological reflexes +/+/+/+, pathologic reflexes (-/-)

Breastfeeding
Till 2 yo
Till 1 yo

Obstetrics Examination

Estimated Due Date

: November 26th, 2014
Fundal height
: 33 cm
Fetal weight estimation
: 3110 gr
Uterine Contraction
: 2x/10 minute
Fetal heart rate
: 140 x/minute
Leopold Maneuver :
Leopold I
: head
Leopold II
: back on rightside
Leopold III
: buttock
Leopold IV
: 4/5

Vaginal toucher : Vulva and vaginal in normal limit, cervical dilatation 4 cm, cervical effacement
70%, amnion sac (-), complete breech presentation
Inspeculo

: not performed

Cardiotocography

Baseline
Variable
Acceleration
Deceleration
Fetal movement
His
Result

: 140 bpm
: normal
: + 5x/20 minutes
:: 7 times for 20 minutes.
:: Non Stress Test reactive

Laboratory examination

Hemoglobin
Hematocrit
Leukocyte
Platelets
Blood type
Protein

: 12,2 g/dL.
: 33 %.
: 10.800/L.
: 186.000 /L.
: O/Rh+.
: -

Working diagnosis
G3P2A0, 43 yo, 36-37 weeks gestation according to first day of last menstrual period,
single live fetus, intrauterine,stage 1 active phase, complete breech presentation

Planning

Observe labour progress, lead labour manouver if maximal dilatation is observed

Follow up

Date

Subjectiv

Objective

Assessment

Novemb

e
Post

Conciousness : P3A0, 43 years old, Observe vital signs

er 26th,

hecting

CM

2014

pain VAS

BP : 110/80 prematurus by total

mmHg

breech extraction

RR: 18 bpm

pervaginam

post partus

Pulse : 84 bpm delivery indicated

S: 36,5oC

by breech

Abdomen :

presentation and

I:

convex, post manual

linea nigra (+), placenta indicated

striae

by retained and

gravidarum

post episioraphy

(+)

indicated by

A:

bowel episiotomy and

sounds

(+), anemia et causa

4x/minute
P

haemorrhagic post

supple, partum ec placenta

pain

on retention.

palpation (-)
Obstetric
Fundal height :
22 cm
Lochia : 50 cc,
rubra
Mobilization:

Planning

Oral Medications :

Cefadroxil 3 x 500 mg
Mefenamic acid 3 x 500

mg
Methergin 3 x0,125 mg

Novemb

(-)

Conciousness : P3A0, 43 years old, -

er 27th,

CM

2014

BP : 120/80 prematurus by total

post partus

mmHg

breech extraction

RR: 18 bpm

pervaginam

Pulse : 84 bpm delivery indicated

S: 36,5oC

by breech

Abdomen :

presentation and

I:

convex, post manual

linea nigra (+), placenta indicated

striae

by retained

gravidarum

placenta and post

(+)

episioraphy

A:

bowel indicated by

sounds

(+), episiotomy and

4x/minute
P

anemia et causa

supple, haemorrhagic post

pain

on partum ec placenta

palpation (-)
Obstetric
Fundal height :
18 cm
Lochia : 20 cc,
rubra
Mobilization:
active

Final diagnosis
Mother:

retention.

Patient may go home

Medication at home :
o Cefadroxil 3 x 500 mg
o Mefenamic acid 3 x 500 mg
o Methergin 3 x0,125 mg

P3A0, 43 years old, post partus prematurus by total breech extraction pervaginam delivery
indicated by breech presentation and post manual placenta indicated by retained placenta and
post episioraphy indicated by episiotomy and anemia et causa haemorrhagic post partum ec
placenta retention.
Baby:
Male, preterm neonates, appropriate for gestational ,age, gestational age 38-39 weeks according
to New Ballard Score , APGAR 4/9, birth weight 2950 gram, birth length = 48 cm , diagnosis
healthy neonate

Case 2
P0A0, 28 years old with bartholin abscess
Identity

Name
Age
Ethnic
Religion
Occupation
Education
Date of admission

: Mrs. E
: 28 years old
: Javanese
: Moslem
: Housewife
: Senior High School
: November 28th 2014

Anamnesis:
Chief complaint
Pain in genital area 1 week before admission.
History of Present Illness
Patient had feel pain around genital area 1 week before admission. Patient also had a
fever 8 days before admission. 5 days before admission patient had complain swelling
around her genital. Patien also had complaint difficult in walking in sitting.
History of Past Illness
History of hypertension
History of diabetes mellitus
History of allergy
History of epilepsy
History of hematologic disease

: denied
: denied
: denied
: denied
: denied

History of urinary tract/ kidney disease : denied

History of trauma
: denied
History of surgery
: denied

History of menstrual cycle

Menarche
Menstrual cycle

: 13 years old
: 28 days, regular, with duration of 7 days
changed 3 pads a day.
dysmenorrhea (-)
: November 8th 2014

First day of last menstrual

Obstetrics History
No.

Date

Gestational

Labor

Age
-

History
-

Sex
-

Birth

Breast

Weight
-

Feeding
-

Contraception History
Physical Examination
General condition
Level of consciousness
Vital Signs
Blood pressure
Heart rate
Respiration rate
Temperature
Weight
Height

: Moderately ill
: Compos mentis
: 120/90 mmHg
: 96 x/minutes
: 22 x/minutes
: 37o C
: 53 kg
: 162 cm

General Examination
Eyes
Mouth
Thorax
Heart
Lung
Mammae
Abdomen
Inspection
Auscultation
Palpation
Percussion
Extremities

: Anemic conjunctiva +/+, icteric sclera -/: wet oral mucosa membrane.
: Regular 1st and 2nd heart sounds, murmur - , gallop
: Vesicular breath sounds +/+, rhonchi -/-, wheezing -/: Areola hyperpigmentation -/-, nipple retraction -/-, breast milk -/: Convex
: Bowel sounds (+), 5 times / minute
: Supel, pain with palpation (-)
: Tympanic in all quadrants
: Edema -/-, CRT < 2 seconds
Physiologic reflex + +
+ +

, pathologic reflexes -/-

Gynecologic Examination
Inspection :V/V abscess in the 8 oclock position, diameter 1,3 cm
Pelvic Examination :
Vaginal toucher
: Was not performed
Inspeculo
: Was not performed
Working Diagnosis
P0A0, 28 years old with bartholin abscess dextra.
Laboratory
Hb: 12,2 g/dl
Ht: 37%
Leukocyte: 10.500/ul
Trombocyte : 397.000/ul
Planning
Pro marsupialization
Operation report

Patient in lithotomy position

Aseptic and antiseptic procedure
Abscess incision
Clean the wound with H2O2 and povidone iodine
Drain installation
Wound was closed with hecting

Treatment after procedure

Observation of patients vital sign after procedure.
Patient is permitted for discharge.
Medications after procedure:
o Flagyl 3 x 500 mg
o Cefadroxil 3 x 500 mg
o Sumagesic 3 x 600 mg
o Tramal 1 x 1
o Kaltrofen supp 1 x 1

Final Diagnosis
P0A0, 28 years old with post marsupialization indicated by bartholin abscess dextra

CASE 3:
G1P0A0, 29 yo, gravid 11-12 weeks according to first day of last menstruation,
with missed abortion
Identity

Name
Age
Ethnic
Religion
Occupation
Education
Date of Admission

: Mrs. F
: 23 years old
: Javanese
: Moslem
: Housewife
: Marketing
: November 28th 2014

Anamnesis
Chief Complaint
Bleeding from genital 4 days before admission.
History of Present Illness
4 days before admission pasien had complain blood which came out from her genital.
About 2 days before admission, the patient had complaints about bright red spot on her panties
and blood clot like chicken liver, but no tissue coming out from her genital. She also felt
abdominal discomfort or pain 1 days before admission. One day before hospital admission, she
visited mid wife. Her mid wife gave her some drugs for pregnancy protector.
History of Past Illness
History of hypertension

: denied

History of diabetes mellitus

: denied

History of allergy

: denied

History of asthma

: denied

History of trauma

: denied

History of surgery

: denied

History of curretage

: denied

History of Menstrual
Patient menarche
Menstrual cycle

: 15 years old
:28 days, regular, with duration of 5-7 days, changed

2 pads a day, dysmenorrhea is denied.

First day last menstrual : June 20th 2014

 Obstetrics History
No.

Year

1.

This

Gestational
Age

Labor History

Sex

Birth

Breast

Weight

Feeding

Contraception History
no
Physical Examination
General condition
Level of consciousness
Vital Signs

: Mildly ill.
: Compos mentis

Blood pressure
Heart rate
Respiration rate
Temperature

: 110/60 mmHg
: 80 times/minute (regular, strong enough, full)
: 20 times/minute (regular)
: 36.8 o C

Weight : 40 kg
Height : 155 cm
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 +/+, nipples retraction -/-, breast milk -/-

Abdomen

Inspection
Auscultation
Palpation
Percussion

Extremities

: Convex, linea nigra (+), striae gravidarum (+)

: Bowel sounds (+), 5 times/minute
: Supple, pain on palpation (-)
: Tympanic in all quadrants
: Warm, edema -/-, CRT < 2 seconds, physiologic reflexes
pathologic reflexes -/-

Gynecologic Examination
Fundal height
Pelvic examination
Inspeculo
Vaginal toucher : Laboratory Examination

: (-)
: stool cell (-), tissue (-), fluksus (+), erosion (-)

+++
+ +

Hemoglobin : 13.9 g/dL

Hematocrit
: 41 %
Leukocyte
: 12.600 cells/l
Thrombocyte : 279.000 cells/l
Blood type
: O/Rh (+)

Working Diagnosis
G1P0A0, 23 yo, gravid 11-12 weeks according to first day of last menstruation, with missed abortion
Planning
Pro USG
USG
USG examination showed missed abortion
Planning
Pro curretage
Treatment after procedure
Observe patients vital signs.
If the condition is stable and no further complication occurs, patient is permitted for discharge
(one day care).
Out-patient medications:
Cefadroxil caps 3 x 500 mg
Mefenamic acid tab 3 x 500 mg
Methergin 2 x 0,125mg tab
Final Diagnosis
P0A1, 23 yo, with post curettage indicated by missed abortion

CASE 4:
G2P1A0, 29 yo, gravid 25-26 weeks according to first day of last menstruation, not in labor,
with chronic hypertension super imposed preeclampsia, with live single fetus, intrauterine,suspect
IUGR
Identity

Name
Age
Ethnic
Religion
Occupation
Education
Date of Admission

: Mrs. S
: 27 years old
: Javanese
: Moslem
: Housewife
: Housewife
: November 29th 2014

Anamnesis
Chief Complaint
Headache 1 day before hospital admission
History of Present Illness
Patient had complain headache since 1 day brfore hospital admission. Headache which
felt by patient had a progressive onset. Patien described the pain at the both side of the head. The
characteristic of the headache was pulsatile.. Patient also complain the vision was blurred.
Epigastric pain was denied. Nausea and vomiting were denied.
History of Past Illness
History of hypertension

: +

History of diabetes mellitus

: denied

History of allergy

: denied

History of asthma

: denied

History of trauma

: denied

History of surgery

: denied

History of curretage

: denied

History of Menstrual
Patient menarche
Menstrual cycle

: 18 years old
:28 days, regular, with duration of 5-7 days, changed

2 pads a day, dysmenorrhea is denied.

First day last menstrual : June 3th 2014

Obstetrics History
No.

Year

1.
2.

2010
This

Gestational
Age

8 months

Labor History

Sex

SC

Birth

Breast

Weight

Feeding

1800

 Contraception History
no
Physical Examination
General condition
Level of consciousness
Vital Signs

: Moderately ill.
: Compos mentis

Blood pressure
Heart rate
Respiration rate
Temperature

: 170/90 mmHg
: 120 times/minute (regular, strong enough, full)
: 32 times/minute (regular)
: 36.8 o C

Weight : 49 kg
Height : 130 cm
Fetal weight estimation : 466 grams (ultrasound)
Fetal heart beat: 148 x/min
Labor estimation: March, 10th 2015

General Examination
Eyes : Anemic conjunctiva -/-, icteric sclera -/ Mouth : Wet oral mucous membrane
Thorax

Heart : regular 1st and 2nd heart sounds, murmur -, gallop -,cardiomegaly
Lung : Vesicular breath sounds +/+, rhonchi -/-, wheezing -/Mammae : Areola hyperpigmentation +/+, nipples retraction -/-, breast milk -/-

Abdomen

Inspection
Auscultation
Palpation
Percussion

Extremities

: Convex, linea nigra (-), striae gravidarum (-)

: Bowel sounds (+), 5 times/minute
: Supple, pain on palpation (-)
: Tympanic in all quadrants
: Warm, edema -/-, CRT < 2 seconds, physiologic reflexes
pathologic reflexes -/-

Gynecologic Examination
Fundal height
Pelvic examination
Inspeculo
Vaginal toucher
Laboratory Examination

Hemoglobin
Hematocrit
Leukocyte

: 14.4 g/dL
: 44 %
: 13.000 cells/l

: 18 cm
::-

+++
+ +

Thrombocyte : 179.000 cells/l

Blood type
: O/Rh (+)
Proteinuria dipstick: +1
Ureum:15 mg/dl
Creatinin:0.4 mg/dl
SGPT:35 U/l
SGOT:49 U/l

Working Diagnosis
G2P1A0, 29 yo, gravid 25-26 weeks according to first day of last menstruation, not in labor,
with chronic hypertension super imposed preeclampsia, with live single fetus, intrauterine,suspect IUGR
Planning

Ringer lactate infusion 500 cc/ 24 hrs

Methyldopa 3x 500 mg p.o.
Nifedipine 3 x 10 mg p.o.
Paracetamol 3x 500 mg p.o
Urinalysis in 24 hours
Cardiotocography

Date

Subjectiv

Objective

Assessment

Planning

e
November
30th, 2014

Conciousness :

G2P1A0, 29 yo,
gravid 25-26

Observe vital signs

Fluid restriction ( RL 500

cc + oral 1000c)
Nifedipine 3x 10 mg
Paracetamol 3x 500 mg
Methyldopa 3 x 500 mg
Aspirin 1x80 mg
Protein quantitative in 24

hrs
USG examination( EFW

Dizzy,puls

CM

atile

BP : 170/120

weeks according

headache

mmHg

to first day of last

(-), nausea

26 bpm

-,

Pulse : 96 bpm

abdominal

S: 36,7oC

pain -

Fetal

heart

hypertension

beat:

170

super imposed

Hadlock 534 grams,GA

preeclampsia,

22w 4/7)

RR:

menstruation, not
with chronic

x/min
Abdomen :
I:

in labor,

convex,

with live single

fetus,

Consultation to internal
medicine department

linea nigra (-),

striae

ct IUGR

gravidarum (-)
A:

bowel

sounds

(+),

4x/minute
P : supple, pain
on

palpation

(-)
Urinalysis:
protein +2
Leukocyte +2
Occult blood +
3
Sediment:
Leukocytes
10-15/LVF
Erythrocytes:L
3-5/LVF
EKG:

intrauterine,suspe

sinus

tachycardia

Consulted ECG results

propanolol tab 1x1

December

(-)

1st, 2014

Conciousness :
CM

G2P1A0, 29 yo,
gravid 22-23

BP : 150/90
mmHg

weeks according
to USG, not in

RR: 18 x/ min

labor,

Pulse : 88 bpm

with chronic

S: 36,7oC

hypertension

Observe vital signs

Aff IVFD stopper

Nifedipine 3x 10 mg
Paracetamol 3x 500 mg
Methyldopa 3 x 500 mg
Aspirin 1x80 mg
Multivitamin 1x1
Renal ultrasound(multiple

Fetal

heart

super imposed

nephrolithiasis dextra1 ,3 x

beat:

144

preeclampsia,

1 cm)

x/min

with live single

Abdomen :
I:

fetus,

convex,

linea nigra (-),

intrauterine,suspe
ct IUGR

striae
gravidarum (-)
A:

bowel

sounds

(+),

4x/minute
P : supple, pain
on

palpation

(-)

2nd

(-)

Conciousness :

december

CM

2014

BP : 150/90
mmHg

gravid 22RR:

24 bpm

23weeks
according to first
day of last

Pulse : 92 bpm
S: 36,7oC
Fetal

G2P1A0, 29 yo,

menstruation, not
in labor,

heart

with chronic

Observe vital signs

Aff urine catheter

Nifedipine 3x 10 mg
Methyldopa 3 x 500 mg
Aspirin 1x80 mg
Doppler USG: no absent
diastolic ,Intercerebellum
2,4 cm 22 3/7 weeks

beat:

148

hypertension

x/min

super imposed

Abdomen :

preeclampsia,

I:

convex,

linea nigra (-),

striae

with live single

fetus,
intrauterine,suspe

gravidarum (-)
A:

ct IUGR

bowel

sounds

(+),

4x/minute
P : supple, pain
on

palpation

(-)

Final diagnosis :
G2P1A0, 29 yo, gravid 22-23 weeks according to ultrasound, not in labor,
with chronic hypertension super imposed preeclampsia, with live single fetus, intrauterine.