KRISDAYANI MARTHA SUKMA (P1337424117012)

VIO WALIYATUN HASNA (P1337424117036)

CHIEF COMPLAINT
"Morning sickness in pregnant women 10 weeks' gestation"

HISTORY OF PRESENT ILLNESS

Mrs. Dewi felt nauseous, vomited when she woke up from her sleep. It usually occurs in the
first months of pregnancy until the end of the first quarter. Mrs. Dewi also felt that she had
been menstruating late since 2 months ago. Can't stand the pungent smells like perfume, even
when her husband is near her she refuses. Inhale the smell of certain foods, Mrs. Dewi will
vomit. Lately he has no appetite, and his weight has dropped to 5kg. He complained that
often the bathroom 3-4x a day to pee. During the day and night he experiences a feeling of
heat because of the increased body temperature. To experience this, he drank warm ginger
after waking up and sometimes he ate biscuits prepared by her husband

SURGICAL HISTORY
Mrs. Dewi has never carried out surgery during her life

MEDICAL HISTORY
Normal
Mrs. Dewi has no history of any illness. Only harmless diseases like coughing, flu

SOCIAL HISTORY
The patient lived in Gajahmada Housing on Tirtoagung Pedalangan Street. Mrs. Dewi has
one husband who lives in the area. and her 32-year-old husband. Patients do not consume
tobacco, alcohol, or other illegal drugs.

FAMILY HISTORY
Fathers and mothers of patients died at the age of 61 and 57 because of plane crashes and
they did not have a history of any disease because they always took care of their health with
regular exercise. In his old age, he regularly ran morning. Mrs. Dewi is the only child in her
family .

Allergies
Mrs. Dewi 25 years old haven’t allergies

Review of System
Constitutional - NAD, has been generally feeling well
Eyes - no changes in vision
ENT - No congestion, no changes in hearing, does not wear hearing aids
Skin/Breast - no rashes
Cardiovascular - No SOB, chest pain, heart palpitations
Pulmonary – no hard to get a breath, no cough
Endocrine - no changes in appetite
Gastro Intestinal - No constipation
Genito Urinary - urination increases
Musculo Skeletal - no joint tenderness or swelling

Physical Examination
General condition normal
Awareness composmentis
Vitals:
Temp 36 C
Pulse 78
RR 20
BP 110/80
General - normal
Eyes - no changes in vision
ENT - No congestion, no changes in hearing, does not wear hearing aids
Neck - No noticeable or palpable swelling, no redness or rash around throat or on face
Lymph Nodes - No lymphadenopathy
Cardiovascular - no carotid bruits
Lungs - no crackles or wheezes
Skin - No rashes, skin warm and dry
Breast – no abnormalities
Abdomen - Normal bowel sounds, abdomen soft and nontender
Genito Urinary – Genital exam normal
Extremeties - No edema, cyanosis or clubbing
Musculo Skeletal - normal range of motion, no swollen or erythematous joints.

Pertinent Diagnostic Tests

PP test (-)
Blood type B
Blood pressure 110/80
HIV test (-)
Hb 11,5

Assessment and Plan

Assesment
Mrs. Dewi 25 years old G1P0A0 10 weeks gestational age, intra uterine, normal birth canal,
general conditions mother and fetus are good. Awareness is composmentis, TD 110/80
mmHg, pulse 78 x/I, breathing 20x/i. Examination head to toe inspection within normal
limits, Ballotemen (+), PP test (-), blood type B, blood pressure 110/80, HIV test (-), Hb 11.5,
USG and CTG have not been done.

In first trimester, mother will feel some discomforts of pregnancy. First,morning

sickness, some will only feel the urge to vomit, and some will actually vomit. This
experience only in first trimester.
 Then, lack of energy/lethargy/fatigue. body is producing new hormones and making a lot
of changes to prepare for human creation. You’re also producing more blood to carry
nutrients to the baby causing increased effort for your heart and other organs. Mental
and emotional stress are also reasons you may be feeling exhausted. You may have
difficulty sleeping later in your pregnancy due to multiple bathroom trips, leg
cramps, and heartburn.

After that, headaches and migraines. Headaches during pregnancy can be a result of

hormonal changes, tension, congestion, constipation, lack of sleep, dehydration,
low blood pressure, low blood sugar, and even caffeine withdrawal. In some cases,
it is caused by preeclampsia.

Main idea: Mrs. Dewi 25 years old G1P0A0 10 weeks gestational age, intra uterine,
normal birth canal, general conditions mother and fetus are good.

Plan :
1. To avoid morning sickness
a. Eat foods rich in protein. Protein helps ease morning sickness.
b. Invest in products that contain ginger.
c. Make sure to take your daily dose of Vitamin B6. 
d. Drink lots of fluids. 
e. Don’t get out of bed too quickly in the morning.
2. To reduce lack of energy and pregnancy fatigue:
a. If possible, take several cat naps.
b. Get up and walk around to get yourself moving.
c. Go to bed early.
d. not eating right before bed(2-3 hours prior).
e. Avoid caffeine
f. Reduce stress
3. To avoid Headaches And Migraines
a. Posture plays an important role. Try to stand up and sit up straight.
b. Get plenty of rest 
c. Exercise (daily 30-minute walk)
d. Eat frequent and well-balanced meals
e. Foods can often be a trigger for headaches or migraines. Keep a food diary and avoid
foods that set off headaches, such as chocolate, caffeine, dairy, meats with preservatives,
etc.
f. Stay hydrated by drinking at least 8 cups of water a day (dehydration can be a trigger)