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  • Reasoning ... TiwuL

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    Vizky Amalia
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    The patient is a 160cm tall, 55kg female with mild vaginal bleeding. On physical examination, she had a slightly tender supra pubic area and mild vaginal bleeding, with positive Chadwick's sign. Speculum examination showed bloody discharge from the cervical os. Vaginal examination found an enlarged, soft uterus with positive Hegar's and Pikacek's signs, and closed cervical os. Laboratory tests showed a hemoglobin level of 12.1 g/dL. Ultrasound examination was also performed. The patient was assessed to be approximately 35 weeks pregnant with a head-down fetus in the right occiput anterior position and fetal heart rate of 150-160 beats per minute.

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    The patient is a 160cm tall, 55kg female with mild vaginal bleeding. On physical examination, she had a slightly tender supra pubic area and mild vaginal bleeding, with positive Chadwick's sign. Speculum examination showed bloody discharge from the cervical os. Vaginal examination found an enlarged, soft uterus with positive Hegar's and Pikacek's signs, and closed cervical os. Laboratory tests showed a hemoglobin level of 12.1 g/dL. Ultrasound examination was also performed. The patient was assessed to be approximately 35 weeks pregnant with a head-down fetus in the right occiput anterior position and fetal heart rate of 150-160 beats per minute.

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    14 views13 pages

    Reasoning ... TiwuL

    Uploaded by

    Vizky Amalia
    The patient is a 160cm tall, 55kg female with mild vaginal bleeding. On physical examination, she had a slightly tender supra pubic area and mild vaginal bleeding, with positive Chadwick's sign. Speculum examination showed bloody discharge from the cervical os. Vaginal examination found an enlarged, soft uterus with positive Hegar's and Pikacek's signs, and closed cervical os. Laboratory tests showed a hemoglobin level of 12.1 g/dL. Ultrasound examination was also performed. The patient was assessed to be approximately 35 weeks pregnant with a head-down fetus in the right occiput anterior position and fetal heart rate of 150-160 beats per minute.

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    of 13

    REASONING

    Created by : tiwuL
    Px .Fisik
    • Kondisi umum : Good , no anaemic
    • TB&BB : 160cm & 55kg
    • VS : normaL
    • Jantung dan Paru-paru : normal
    • Px.Abdomen :
    - kontur normal
    - Palapasi : Slight tenderness on d’supra pubic
    - Massa abdomen : (-)
    - Uterus : (-)
    • Inspeksi : mild vaginal bleeding,tnd Chadwick (+)
    • Px.Speculum : fluxus (+) dr OUE
    • Vaginal toucher :
    1. Portio : soft ; cervical motion
    tenderness : not found
    2. Uterine Ostium : closed
    3. Uterus size : rather enlarged and soft
    - Hegar sign(+)
    - Pikacek sign (+)
    4. Adnexal area : no mass , no tenderness
    5. Douglas pouch : Bulging not found , no
    tenderness
    Pemeriksaan Fisik Umum
    • Meliputi pemeriksaan tanda vital, yaitu tekanan
    darah, nadi, respirasi dan suhu. Pemeriksaan
    fisik lengkap dari kepala sampai ujung kaki
    untuk menemukan apakah ada kelainan,
    termasuk status gizi, tinggi dan berat badan.
    Dan pemeriksaan tanda – tanda kehamilan
    meliputi wajah, dada, abdomen dan genetalia
    eksterna dan interna serta pemeriksaan
    panggul.
    Pemeriksaan Fisik Umum :

    Ø Keadaan umum , gizi, bentuk tubuh, kesadaran


    Ø Tanda vital : tekanan darah, frekuensi nadi,
    frekuensi nafas
    Ø Apakah ada anemia, sianosis, ikterus, dispneu
    Ø Keadaan jantung dan paru
    Ø Edema +/-
    Ø Refleks terutama refleks lutut
    Ø Berat badan → perhatikan perubahan berat
    badan setiap pemeriksaan
    Ø Tinggi badan
    Lab. Examination
    • Hb : 12.1 gr%
    Px .Obsetric
    • Fundal height is 35cm above symphysis
    • Fetus is head presentation,back on d right
    • Fetal heart rate is 150-160 x/minutes
    • Contraction once in every 3-4minutes , 40s ,
    strong
    Speculum examination
    Fluxus positif dan cukup banyak .
    Lab. Result
    • Hb : 10.3 gr%
    USG
    Pemeriksaan d9 spekuLum
    • Memakai aLat (spekuLum)
    • Untuk memeriksa :
    dinding vagina  misaL ada cairan,
    darah, fluor
    porsio vaginalis  bentuk,
    pengambilan usap vagina atau serviks

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