CHAPTER I

CASE REPORT
1. PATIENT STATUS

A. IDENTITY
Name : Mrs. S
Age : 27
Sex : Female
Medic Record Numb : 12.25.75
Adress : Batu Aji
Occupation : Housewife
Religion : Islam
Date of Admission : 21th February 2017 09.20 PM
Spouse : Mr. Aldi
Age : 35
Adress : Batu Aji
Occupation : Private employe
Religion : Islam

B. ANAMNESIS
1. Autoanamnesis givent by : Patient
2. Main Complaint
A patient aged 27 years came to the hospital emergency room.
April 21st, 2017 9:20 pm hour with fill out fresh blood from genitals(+)
since 5 days ago.
3. Disease History now
Low back pain radiating to the placenta does not exist
Close of blood mixed mucus from the genitals exist
Close the water that many of the pubic does not exist
The first day of last Menstruasi : 15/07/2016
Interpretasion Birth: 22/04/17.
RHM: Nausea (-), vomiting (-), vaginal bleeding (+)
ANC: Reguler control to public health.
Last USG 19/03/2017 with result is placenta previa totalis
Menstruasi History : Menarche : 13 years old, menstruasi circle
35 days, duration 5-7 days, pain (-)
4. Once Disease History

Hypertension : (-)

Diabetes Mellitus : (-)

Heart Disease : (-)

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 Tumor disease and Cancer : (-)

5. Family Disease History

Hypertension : (-)

Diabetes Mellitus : (-)

Heart Disease : (-)

Tumor disease and Cancer : (-)

6. Marriage History : once in 2013

7. Obstetry History

1. 2014, female, weight 2.800 gram pervaginam in midwife

2. 2017 now

8. Contaception History: (-)

9. Imunisasion History : (-)

C. FISICAL EXAMINATION
1. General Condition
General condition : Moderat
Sensorium : Compos mentis
GCS : E4:V5:M6
Weight : 48 kg
Heigh : 150 cm

2. Vital Sign
BP : 120/60 mmHg
P : 100 x / menit
T : 37,20 C
RR : 23 x/ menit

3. Sistemik examination

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a. Eyes : Conjungtiva anemis (-/-), sklera ikterik (-/-).
b. Neek : enlarged lymph nodes (-),enlarged thyroid gland(-)
c. Thoraks
Pulmo
Inspeksion : simetris (+/+) ,retraksi(-/-)
Palpasion : simetris movement (+/+),between the ribs is not
widened
Perkusion : Fokal fremitus (+/+)
Auskultasi :Pulmo sound( +/+) vesikuler, ronchi (-/-), wheezing
(-/-)

Cor
Inspeksion : Ictus cordis (-)
Palpasion : Ictus cordis palpable at ICS V linea midclavicula
sinistra
Perkusioon : cor border within normal limits
Top right : ICS II linea parasternalis dextra
Bottom right : ICS IV linea parasternalis dextra
Top left : ICS II linea parasternalis sinistra
Bottom left : ICS IV line midclavicularis sinistra
Auskultasi : Heart sound I dan II normal reguler, murmur (-),
gallop (-)

d. Abdominal
Hepar : difficult to assess
Lien : difficult to assess

e. Ekstrimitas
Superior : akral warm, clubbing finger (-), CRT < 3
Inferior : akral warm, eodema (-)

4. Status Obstetry
Eksternal examination
- FUH : 15 cm
- FWP : 510 gram
- FHR : 157 x/i

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 - Leopold I : FUH upper 2 finger of umbilikal
- Leopold II : Prisioners palpable hard flat elongated impressed
backs
- Leopold III : Palpable hard impressed head
- Leopold IV : convergent
- His : (-)
Internal Examination
- Are not done
D. WORK UP

Laboratory findings April 21st 2017

Examination Result Interpretation

Hemoglobin 11,3 11-16,5 gr/dl
Leukosit 17.800 3500-10.000 /ul
Hematokrit 40 35-50 %
Eritrosit 5,3 3,6 5,3 juta/ul
Trombosit 75 150.000-500.000/ul
MCV 75,6 80-97 fl
MCH 25,2 26,5-33,5 pg
MCHC 33,4 31,5-33,5 g/dl
SGOT 53 P=<40 W=<32 U/I
SGPT 31 P=<40 W=<32 U/I
Ureum 60 10-50 mg/dl
P=0,7-1,2 W=0,5-1,0
Creatinin 2,0
mg/dl
GDS 87 <200 mg/dl
Albumin 2,1 3,4-4,8 g/dl
Natrium 131 136-146 mmol/L
Kalium 3,6 3,5-5,1 mmol/L
Klorida 106 98-107 mmol/L

Urinalisa
Warna Kuning Tua Kuning
Kejernihan Keruh Jernih
Berat Jenis 1.015 1.003-1.030
Ph 5,0
Lekosit Negatif Negatif
Nitrit Negatif Negatif
Protein + Negatif
Glukosa Negatif Negatif
Keton Negatif Negatif
Urobilinogen Negatif Negatif

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 Bilirubin Negatif Negatif
Eritrosit + Negatif
Sedimen
Lekosit 1-3 0-5 /LPB
Eritrosit >100 0-2/LPB
Epitel 10-20 2-10?LPB
Bakteri Negatif Negatif
Kristal Negatif Negatif
Silinder 3-5 0-2/LPK

E. WORKING DIAGNOSIS
G2P1A0H1 gravid 37-38 + Plasenta Previa Totalis

F. EARLY MANAGEMENT
Therapy
Dr.Ni Made Indri Sp.OG

IVFD RL 20 gtt

Inj ceftriaxon 2 x 1 g

Inj Dexametason 2amp/

Planning sc on date 22/April/2017

Dr. Jaga igd

Put the chateter

Check urine and CBC

G. PATIENT ASSESMENT
Patient Came To Emergency Room
April 21st 2017 09.20 AM
April 23th 2017 S/ fill out fresh blood from genital(+) since 5 days ago
09.20 AM O/
General condition: Moderat

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 Sensorium: Compos mentis
BP : 120/60 mmHg
P : 100 x / menit
T : 37,20 C
RR : 23 x/ menit
FHR : 157x/i
A/ G2P1A0H1 gravid 37-38 minggu + Plasenta Previa

P/ dr. Ni Made Indri Sp.OG

- IVFD RL 20 gtt
- Inj ceftriaxon 2 x 1 g
- Dexametasone 2 amp

dr. Jaga igd

- Put the chateter

- Check urine and CBC

Patient Came to VK
April 22th 2017, 15.30 PM
FOLLOW UP
April 21th 2017 S/ blood from vagina (+)
15.30 PM O/
General condition: Moderat
Sensorium: Compos mentis
BP: 110/70 mmHg
P: 70x/minute
RR: 22x/minute
T: 36.2 C
FHR : 120x/i
A/ G2P1A0H1 gravid 37-38 minggu + Plasenta previa

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 totalis
P/ dr. Ni Made Indri Sp.OG
RL 20 tpm
Inj ceftriaxone 2x1gr
Inj dexamethasone 2 amp

Planning sc on date 22/04/2017

FOLLOW UP MAWAR
April 22th 2017 Post surgery
09:00 PM S/ dizzy (+), surginal wound pain (+),
O/
General condition: Moderat
Sensorium: Compos mentis
BP: 130/80 mmHg
P: 82x/minute
RR: 20x/minute
T: 36.6 C

A/ P2A0H2 post SC a/i placenta previa

P/
- IVFD RL 20tpm
- Cefotaxim 2x 1g
- Metronidazol 3x500 mg fls
- Keterolac 2x1 amp
- Pronalges 2x2 supp
- Transamin 3x1 amp
Planning cek DL post op

April 23th 2017 S/ Dizzy (+),surginal wound pain (+), flatus (+),
O/
General condition: Moderat
Sensorium: Compos mentis
BP: 110/90 mmHg

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 P: 76x/minute
RR: 20x/minute
T: 36.8 C
Vaginam bleeding (+)
A/ P2A0H2 post SC a/i Plasenta Previa

P/ dr.Ni Made Indri Sp.OG

- IVFD RL 20tpm
- Cefotaxim 2x 1g
- Metronidazol 3x500 mg fls
- Keterolac 2x1 amp
- Pronalges 2x2 supp
- Transamin 3x1 amp
Planning cek DL post op

Laboratory findings February 23th 2017

Examination Result Interpretation

Hemoglobin 10,3 11-16,5 gr/dl
Leukosit 17.800 3500-10.000 /ul
Hematokrit 40 35-50 %
Eritrosit 5,3 3,6 5,3 juta/ul
Trombosit 75 150.000-500.000/ul
MCV 75,6 80-97 fl
MCH 25,2 26,5-33,5 pg
MCHC 33,4 31,5-33,5 g/dl
SGOT 53 P=<40 W=<32 U/I
SGPT 31 P=<40 W=<32 U/I
Ureum 60 10-50 mg/dl
P=0,7-1,2 W=0,5-1,0
Creatinin 2,0
mg/dl
GDS 87 <200 mg/dl
Albumin 3,1 3,4-4,8 g/dl
Natrium 131 136-146 mmol/L
Kalium 3,6 3,5-5,1 mmol/L
Klorida 106 98-107 mmol/L

Urinalisa
Warna Kuning Tua Kuning
Kejernihan Keruh Jernih

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 Berat Jenis 1.020 1.003-1.030
Ph 5,0
Lekosit Negatif Negatif
Nitrit Negatif Negatif
Protein Negatif Negatif
Glukosa Negatif Negatif
Keton Negatif Negatif
Urobilinogen Negatif Negatif
Bilirubin Negatif Negatif
Eritrosit + Negatif
Sedimen
Lekosit 1-3 0-5 /LPB
Eritrosit >100 0-2/LPB
Epitel 10-20 2-10?LPB
Bakteri Negatif Negatif
Kristal Negatif Negatif
Silinder 3-5 0-2/LPK

April 24th 2017 S/ dizzy (-), surginal wound pain (-),

O/
General condition: Moderat
Sensorium: Compos mentis
BP: 120/80 mmHg
P: 82x/minute
RR: 20x/minute
T: 36.6 C

A/ P2A0H2 post SC a/i placenta previa

P/ IVFD RL 20tpm
- Cefotaxim 2x 1g
- Metronidazol 3x500 mg fls
- Keterolac 2x1 amp
- Pronalges 2x2 supp
- Transamin 3x1 amp

April 25th 2017 S/ flatus (+), BAB (+), BAK (+)

O/

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General condition: Moderat
Sensorium: Compos mentis
BP: 110/90 mmHg
P: 76x/minute
RR: 20x/minute
T: 36.8 C
Vaginam bleeding (-)
A/ P2A0H2 post SC a/i Plasenta Previa

P/ dr.Ni Made Indri Sp.OG

Cefixime 2x200mg
Asam mefenamat 3x1
SF 1X1
Vit c 2x1
BLPL

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