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7/29/2019 English Case

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Name : Silvia nettyAge : 37 years oldMR No. : 75 25 42Date : NOvember 2

nd, 2011

Anamnesis :A 37 years old patient was admitted to the Ward Room of Dr. M. Djamil Central General

Hospital on November 2nd, 2011 at 11.00 am sent by Poliklinic with D/ G3P1A1L1 term pregnancy37-38 weeks previous CS on indivation contracted pelvic pro elective CS

Present Illness History :

Feeling of pain from waist to region which referred to the groin was absent.

Bloody show from the vagina was absent.

Fluid leakage from the vagina was absent.

No massive vaginal bleeding.

Amenorrhea since 9 months ago.

First date of last menstrual period forgetEstimation date of delivery cannot be dievaluated

Fetal movement was felt since 5 months ago.

No complain of nausea, vomitting and vaginal bleeding neither during early pregnancy norlate pregnancy.

Prenatal care to Poliklinik Dr.M.Djamil Hospital regularly.

Menstruation History : menarche at 13 years old, regular cycle, once in 30 days which last for5 to 6 days each cycle with the amount of 2-3 times pad change/day without menstrual pain.

Previous Illness History :There wasnt previous history of heart, lung, liver, kidney, DM and hypertension.

Family Illness History :There wasnt history of hereditary disease, contagious and physicological illness in the family.

Marriage history : once in 2000History of pregnancy/abortion/delivery : 3/1/1I. 2000, Abortus,curetage,3 months, privat hospital,obstetriciantII. 2002,female,3400gr, term pregnancy, CS on indication of contrated pelvic,Dr. M jamil

hospital, alive, the wound heal in 7 daysHistory of family planning : (-)History of immunization : (-)

Physical Examination :GA Cons BP PR RR T Body Weight Body HeightMdt CMC 120/70 80 20 af 67 kg 143 cmEyes : Conjunctiva wasnt anemic, Sclera wasnt ictericNeck : JVP 5-2 cmH2O, tyroid gland no enlargementChest : H/L normalAbdoment : OR

Genitalia : ORExtremity : Edema -/-, Physiological Reflex +/+, Pathological Reflex -/-

Obstetric Record :Face : Chloasma gravidarum was positiveBreast : Both enlarge, areola/nipple hyperpigmentation, colostrum (+)Abdoment :

I : Enlarge according to term pregnancy, median line hyperpigmentation, striaegravidarum (+), cicatrix (+) linea mediana previous CS


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Pa : L1 : Uterine fundal was palpable 3 finger below xyphoideus cartilageA large nodular mass was palpated

L2 : A hard and resistance structure was felt on the right sideNumerous small, irregular were felt on the left side

L3 : A hard mass was palpable and floatingL4 : not doingUterine Fundal Height : 31 cm Estimated fetal body weight : 2790 grUterine contraction : (-)

Pe : TympaniAu : Peristaltic sound was normal Fetal Heart Sound :148x/minute

Genitalia : I V/U normal

VT nonePortio was thick 1,5cm, post, moderateAmniotic sac cannot be evaluatedHead palpable was floating.

Pelvic Inlet : Promontory can be reachedInominate line palpable -3/4Sacrum bone : concave

Pelvic side wall : straightIschiadic spine : protruded

Coccygeus bone : moveable

Arc of pubic : < 90Pelvic Outlet : Inter tuberous distance cannot be passed through by normal adult fist

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CTG : Baseline : 140 dpm

Variability : 5-15 dpmAkseleration : +/positifDeseleration : -/negatif

Fetal Movement : +/positifContracted : -/negatif

Impresstion : reactive

November, 3th

2011At 10.05am : TPPCS was perfomedAt 11.05 am : finished TPPCS

At 10.10 am :Afemale baby was born by TPPCS with 2778 gram in weight, 49 cm in height,Apgar score : 8/9.Placenta was born with a little pull on umibilical cord, complete, 1 piece.

Size was 17 x 16 x 3 cm, weight 500 gramUmbilical cord was approximately 50 cm in length with paracentral insertion.

Bleeding during operation 250 cc

D/ P2A1L2 post TPPCS on indication of contracted pelvic primary CSMother Child were in care

management/ : Observe after operation

english case

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