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    Patient 1: Pratiwi

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    Patient 1 is a 31-year-old woman, G4P2A1, who presented for routine antenatal care at 22-23 weeks gestation. She has a history of two prior C-sections. On examination, fundal height was consistent with gestation and fetal heart rate was normal. Ultrasound confirmed a singleton intrauterine pregnancy of 22-23 weeks with a head-down fetus. Patient 2 is a 23-year-old woman, G2P1001, who also presented for routine antenatal care. She is at 36-37 weeks gestation. Examination findings were normal and ultrasound showed a head-down fetus estimated to weigh 2765 grams, appropriate for gest

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    Patient 1: Pratiwi

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    Rizkilbs Lbs
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    Patient 1 is a 31-year-old woman, G4P2A1, who presented for routine antenatal care at 22-23 weeks gestation. She has a history of two prior C-sections. On examination, fundal height was consistent with gestation and fetal heart rate was normal. Ultrasound confirmed a singleton intrauterine pregnancy of 22-23 weeks with a head-down fetus. Patient 2 is a 23-year-old woman, G2P1001, who also presented for routine antenatal care. She is at 36-37 weeks gestation. Examination findings were normal and ultrasound showed a head-down fetus estimated to weigh 2765 grams, appropriate for gest

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    Patient 1 is a 31-year-old woman, G4P2A1, who presented for routine antenatal care at 22-23 weeks gestation. She has a history of two prior C-sections. On examination, fundal height was consistent with gestation and fetal heart rate was normal. Ultrasound confirmed a singleton intrauterine pregnancy of 22-23 weeks with a head-down fetus. Patient 2 is a 23-year-old woman, G2P1001, who also presented for routine antenatal care. She is at 36-37 weeks gestation. Examination findings were normal and ultrasound showed a head-down fetus estimated to weigh 2765 grams, appropriate for gest

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    6 views16 pages

    Patient 1: Pratiwi

    Uploaded by

    Rizkilbs Lbs
    Patient 1 is a 31-year-old woman, G4P2A1, who presented for routine antenatal care at 22-23 weeks gestation. She has a history of two prior C-sections. On examination, fundal height was consistent with gestation and fetal heart rate was normal. Ultrasound confirmed a singleton intrauterine pregnancy of 22-23 weeks with a head-down fetus. Patient 2 is a 23-year-old woman, G2P1001, who also presented for routine antenatal care. She is at 36-37 weeks gestation. Examination findings were normal and ultrasound showed a head-down fetus estimated to weigh 2765 grams, appropriate for gest

    Copyright:

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    of 16

    Patient 1

    PRATIWI
    Mrs. P, 31 yo, G4P2A1, Melayunese, Moslem, Senior High School,
    Housewife. Married to Mr. K, 33 yo, Bataknese, Moslem, Bachelor,
    Enterpreneur. The patient was come to Policlinic USU General Hospital
    on June 11th 2020 with :

    Cc : ANC
    E : This patient is a routine patient at USU Hospital outpatient clinic
    for antenatal care. History of labor contraction (-), history of bloody
    slime (-), history of amniotic fluid leakage (-). Micturition and
    defecation within normal limit.
    • Previous illness : -
    • Previous medication : -
    • Previous surgery : C-Section 2 time
    • LMP : 7/01/2020
    • EDD : 14/10/2020
    • ANC : Midwife 1 time, Obstetrician 1 time

    History of Pregnancy
    1. Male, Aterm, 3100 gr, C-Section, Obstetrician, 9 yo, Healthy
    2. Male, Aterm, 3000 gr, C-Section, Obstetrician, 2 yo, Healthy
    3. Abortus
    4. Current Pregnancy
    Vital Signs
    Sens : Alert Anemia : (-)
    BP : 110/70 mmHg Icteric : (-)
    Pulse : 78 bpm Dyspnoe : (-)
    RR : 18 bpm Cyanosis : (-)
    Temp : 36,8°C Oedem : (-)

    General state : Normal BW: 64 kg, BH: 155 cm


    Nutritional State : Normal UAC : 24 cm
    Illness State : Normal

    Generalized State :
    Head : Pale palpebra conjuctiva inferior (-), icteric sclera (-)
    Neck : Lymph node enlargement (-), thyroid gland enlargement (-)
    Cor : Within no abnormality
    Thorax : Respiratory sound : Vesicular (+/+)
    Additional sound : Rales (-/-), Wheezing (-/-)
    Superior Ext : Within normal limit
    Inferior Ext : Pretibial oedem (-/-)
    Obstetrical State

    Abdomen : Symmetrically enlarged


    Fundal Height : As level as umbilicus (22cm)
    Tension part : Left
    Lower part : Head
    Uterine Contraction : -
    Fetal movement : (+)
    Fetal Heart Rate : (+) 140x/i, regular

    Gynecological State
    Vaginal examination : not performed
    USG TAS
    USG TAS
    ‐ Singleton Fetus, live Fetus
    ‐ Fetal movement (+), Fetal Heart Rate (+) 131 bpm, regular
    ‐ BPD : 53.4 mm
    ‐ HC : 194.6 mm
    ‐ AC : 117.0 mm
    ‐ FL : 39.0 mm

    Conclusion : IUP (22-23) wga + Head Presentation + Live


    Fetus
    Diagnosis
    Prev. C-Section 2 times + MG + IUP ( 22-23) wga + Head Presentation +
    Live Fetus

    Therapy
    Folic Acid tab 2x1

    Planning
    Control in 1 month later

    Reported to supervisor on duty Prof. Dr. dr. M. Fidel Ganis Siregar,


    M.Ked (OG), SpOG(K)  approved
    Patient 2
    Maria
    Mrs. M, 23 yo, G2P1001, Bataknesse, Christian, Senior High School,
    Housewife. Married to Mr. O, 26 yo, Bataknese, Christian, Bachelor,
    Enterpreneur. The patient was come to Policlinic USU General Hospital
    on June 11th 2020 with :

    Cc : ANC
    E : This patient is a routine patient at USU Hospital outpatient clinic
    for antenatal care. History of labor contraction (-), history of bloody
    slime (-), history of amniotic fluid leakage (-). Micturition and
    defecation within normal limit.
    • Previous illness : -
    • Previous medication : -
    • Previous surgery : -
    • LMP : 14/09/2019
    • EDD : 21/06/2020
    • ANC : Midwife 1 time, Obstetrician 1 time

    History of Pregnancy
    1. Female, Aterm, 2900 gr, C-Section, Obstetrician, 2 yo, Healthy
    2. Current Pregnancy
    Vital Signs
    Sens : Alert Anemia : (-)
    BP : 120/70 mmHg Icteric : (-)
    Pulse : 76 bpm Dyspnoe : (-)
    RR : 20 bpm Cyanosis : (-)
    Temp : 37,1°C Oedem : (-)

    General state : Normal BW: 65 kg, BH: 156 cm


    Nutritional State : Normal UAC : 25 cm
    Illness State : Normal

    Generalized State :
    Head : Pale palpebra conjuctiva inferior (-), icteric sclera (-)
    Neck : Lymph node enlargement (-), thyroid gland enlargement (-)
    Cor : Within no abnormality
    Thorax : Respiratory sound : Vesicular (+/+)
    Additional sound : Rales (-/-), Wheezing (-/-)
    Superior Ext : Within normal limit
    Inferior Ext : Pretibial oedem (-/-)
    Obstetrical State

    Abdomen : Asymmetrically enlarged


    Fundal Height : As level as umbilicus (22cm)
    Tension part : Left
    Lower part : Head
    Uterine Contraction : -
    Fetal movement : (+)
    Fetal Heart Rate : (+) 142x/i, regular

    Gynecological State
    Vaginal examination : not performed
    USG TAS
    USG TAS
    ‐ Singleton Fetus, live Fetus
    ‐ Fetal movement (+), Fetal Heart Rate (+) 131 bpm, regular
    ‐ BPD : 88.4 mm
    ‐ HC : 321.4 mm
    ‐ AC : 313.4 mm
    ‐ FL : 71.4 mm
    ‐ S/D ratio :2.56
    ‐ EFW :2765 gram

    Conclusion : IUP (36-37) wga + Head Presentation + Live


    Fetus
    Diagnosis
    SG + IUP ( 36-37) wga + Head Presentation + Live Fetus

    Therapy
    Folic Acid tab 2x1

    Planning
    Control in 2 weeks later

    Reported to supervisor on duty Prof. Dr. dr. M. Fidel Ganis Siregar,


    M.Ked (OG), SpOG(K)  approved

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