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  • Mrs. Afiah /29 TH MRS Tgl. 23-03-2017 Pkl. 22:15 WITA Subjective

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    Rully Syahrizal
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    1. Mrs. Afiah is a 29 year old pregnant woman, 8-9 weeks gestation, who presented to the hospital with nausea, vomiting for a week including blood in vomit, and abdominal pain. She has a history of hyperthyroidism and hypertension. 2. On examination, she had a blood pressure of 160/100 mmHg, heart rate of 120 bpm, temperature of 38.1°C. Fetal ultrasound was unremarkable. 3. She was diagnosed with an 8-9 week pregnancy, history of ectopic gestation, and hyperthyroidism. Her treatment plan included IV fluids, antacids, antiemetics, vitamins, and consultation with

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    1. Mrs. Afiah is a 29 year old pregnant woman, 8-9 weeks gestation, who presented to the hospital with nausea, vomiting for a week including blood in vomit, and abdominal pain. She has a history of hyperthyroidism and hypertension. 2. On examination, she had a blood pressure of 160/100 mmHg, heart rate of 120 bpm, temperature of 38.1°C. Fetal ultrasound was unremarkable. 3. She was diagnosed with an 8-9 week pregnancy, history of ectopic gestation, and hyperthyroidism. Her treatment plan included IV fluids, antacids, antiemetics, vitamins, and consultation with

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    © All Rights Reserved
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    21 views5 pages

    Mrs. Afiah /29 TH MRS Tgl. 23-03-2017 Pkl. 22:15 WITA Subjective

    Uploaded by

    Rully Syahrizal
    1. Mrs. Afiah is a 29 year old pregnant woman, 8-9 weeks gestation, who presented to the hospital with nausea, vomiting for a week including blood in vomit, and abdominal pain. She has a history of hyperthyroidism and hypertension. 2. On examination, she had a blood pressure of 160/100 mmHg, heart rate of 120 bpm, temperature of 38.1°C. Fetal ultrasound was unremarkable. 3. She was diagnosed with an 8-9 week pregnancy, history of ectopic gestation, and hyperthyroidism. Her treatment plan included IV fluids, antacids, antiemetics, vitamins, and consultation with

    Copyright:

    © All Rights Reserved
    Download as PPTX, PDF, TXT or read online from Scribd
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    of 5

    1. Mrs.

    Afiah /29 th
    MRS tgl. 23-03-2017 pkl. 22:15 WITA

    Subjective :
    Patient came to hospital with nausea and vomitting
    since a week ago. She vomit 5-10 times a day,
    recently there is blood stain in the vomits. She also
    felt pain in epigastrium.

    R/ ANC : twice at midwife


    R/ Contraception : Calendary
    History of illness : Hyperthyroid on treatment,
    Hypertension
    Family History : Hypertension

    1
    LMP : 28-1-2017
    8-9 wks
    BE : 04-11-2017

    Menstruation History
    Menarche : 12 years old
    Menstruation Cycle : 28 days, for 7days, dysmenorrhea
    (-)

    Married : 1x For 9 years

    Obstetrical History :
    1. 2008/
    aterm/Spontaneous.Head/Midwife/Male/2500g/alive
    2. 2015/aterm/Spontaneous.Head/Midwife/Female/290
    0g/alive
    Objective of VK ( 23-3-2017 pkl. 22:15):

    Main status

    GCS: E4V5M6 A(-) I(-) C(-) D(-)


    BP: 160/100 mmHg HR: 120x/mnt RR: 20x/mnt Tax:
    38,1oC
    Cor : S1/S2 single, murmur(-), gallop(-)
    Pulmo : ves(+/+), rh(-/-), wh(-/-)
    Extremity:, edema (-)

    Obstetrical Status
    FU unpalpable

    3
    Diagnosis:
    G3P2A0 8-9week + HEG + Hyperthyroid

    Planning:
    IVFD RL 20 tpm
    Inj. Ranitidin 2x1
    Inj. Ondansetron 3x1
    Drip Neurobion 1x1
    Pro Consult Internist
    Check FT4,T3

    4
    Hasil Laboratorium
    23/03/2017
    Hb 12,0 g/dl
    WBC 3500/ul
    PLT 166rb/ul

    Hct 38.9 %

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