Case 2

G4P3, 33 years old, 7-8 weeks

gravid according to first day
of last menstrual period with
hiperemesis gravidarum and
urinary tract infection

Identity
Name
: Mrs. S
Age
: 33 years old
Ethnic
: Betawi
Religion
: Moslem
Occupation
: Housewife
Education
: Primary School
Date of admission
: June 8th 2015
at 13.05

Anamnesis

Chief complaint

Nausea and vomiting accompanied by headache

since 2 months before admissions .

History of Present Illness

Patient came with complain of nausea,
vomiting and headache since 2 months ago.
Nausea and headche are felt all day long, and
caused the patient having problem with eating. She
could only ate 2-3 spoonfull of food, before getting
nausea. As for vomiting are felt every morning,
each vomit contain yellowish aqueous fluid without
pulp about +/- 300cc. She has no other complaint

History of Past Illness

History
History
History
History
History
History

of
of
of
of
of
of

denied
History of
History of
History of
Antenatal
doctor)

hypertension
: denied
diabetes mellitus : denied
allergy : denied
epilepsy
: denied
hematologic disease : denied
urinary tract/kidney disease
:
trauma : denied
surgery : denied
cronic infection : denied
Care
: twice (midwife and

History of menstrual cycle

Menarche : 9 years old
Menstrual cycle : 30 days, regular, with
duration of 3 days per month, changed 3
pads a day, dysmenorrhea (-)
First day of last menstrual period
: April
1th 2015

Marital history: married once for 12

year.

Contraception History: yes,

progesterone injection each 3 month.
For 2 years and stoped at January 2015

Physical examination
General condition
: calm
Level of consciousness
mentis
Vital Signs

: compos

: 120/70 mmHg
Blood pressure
: 80x/minutes
Heart rate
Respiration rate
: 20x/minutes
Temperature : 36,5o C
Body

weight before pregnancy: 58kg

Body weight on admission
: 58 kg
Body height
: 157 cm
Body Mass Index
: 23,5 kg/m2

General examination
Eyes
: anemic conjunctiva
-/-,
icteric sclera -/Mouth : wet oral mucous
membrane
Thorax
Heart : regular 1st and 2nd heart sounds,
murmur - , gallop
Lung : vesicular breath sounds +/+,
rhonchi -/-,
wheezing -/ Mammae : areola hyperpigmentation +/+,
nipple retraction -/-, breast milk -/-

General examination (2)

Abdomen

Inspection : convex, linea nigra +, striae

gravidarum
Auscultation : bowel sounds (+), 3-4 times /
minute
Palpation
: supple, pain with palpation (+)
hypogastric and bilateral iliac region,
hepatomegaly palpable +/- 3cm underneath
arcus costae
Percussion : tympanic in all quadrants except
dullness at RUQ

Extremities
: edema -/-, CRT < 2s
physiologic reflex (+/+/+/+),
pathologic reflexes (-)

Gynecologic examination
First

day of the last menstrual

period: April 1th 2015
Inspection
: fluor albus (-)
Pelvic Examination :
Inspeculo
: not done
Vaginal toucher : not done

Laboratory examination
Blood Examination
Hemoglobin
Hematocrit
Leucocyte
Trombocyte
Blood type
HbsAg

:
:
:
:
:

: 11,1 g/dl
32%
5.400/uL
197.000/uL
O+
-

Laboratory examination

Urine Analysis
Glucose
: Protein : Bilirubine
: Urobilinogen : pH
:7.5
Density:1015
Occult blood : +
(one)
Ketone : Nitrite :-

Leucocyte
(three)
Sediment

:+++

Leucocyte
Eritrocyte
Epithelial
Cylinder
Crystal : Bacteria
Others :-

:18-20
:1-2
:+
::-

Working diagnosis
G4P3, 33 years old, 7-8 weeks gravid according
to first day of last menstrual period with
hiperemesis gravidarum and urinary tract
infection

Planning
1.Cefotaxime 3x1g IV
2.Primperan 3x1 ampoules drip IV
3.Neurobion 1 ampoules drip IV
4.Ranitidin 2x1 ampoules drip IV
5.IVF Futrolit 1500cc/24 hours

FOLLOW UP

Date
9th of
June
2015
05.00
am

Subjective
Objective
Nausea
General
(-),
: moderately ill
Vomiting condition
(-),
headache Level of
(+)
: Compos
consciousn
defecation
mentis
ess
(-), void
(+),
complains Vital signs
felt better
than
o Blood
: 110/70
yesterday.

pressure
mmHg
o Heart
: 90x/minutes
rate
o
:
Respiratory 23x/minute
rate
s
o Body
temperatur : 36.7C
e
Physical
Palpable
Examinatio hepatomeg
n
aly

Assesment

Planning
G4P3, 33 years 1. Repeat urine
analysis 24 hour
old, 7-8
after antibiotics
weeks gravid given

according to
2. Cefotaxime 3x1g
first day of
last menstrual IV
period with
4.Neurobion 1
hiperemesis ampoules drip IV
gravidarum
and urinary
5. Ranitidin 2x1
tract infection ampoules drip IV
6. IVF Futrolit
1500cc/24 hours
7.Primperan 3x1
ampoules drip IV

Date
10th of
June
2015

05.00
am

Subjective

Objective

Nausea General
: calm
(-),
condition
Vomiting
(-),
Level of
headach consciousn : Compos
mentis
e (-)
ess
defecatio
n (+),
void (+) Vital signs

o Blood
: 110/60
pressure
mmHg
o Heart
: 64x/minutes
rate
o
:
Respiratory
20x/minutes
rate
o Body
temperatur : 36.3C
e
Physical
Palpable
Examinatio hepatomeg
n
aly

Assesment

Planning

G4P3, 33 years
old, 7-8
- Patient Discharged
weeks gravid
->
according to Cefotaxime
Cefadroxi l3x500mg
first day of
last menstrual po
period with
Primperan IV ->
hiperemesis 3x10mg po
gravidarum
and urinary
Stop ranitidine
tract infection
Stop Neurobion

Aff IVF

Control in 1 week

Laboratory examination
(10 June 2015)

Urine Analysis
Glucose : Protein : Bilirubine
: Urobilinogen : (+)
pH
:8.5
Density : <1005
Occult blood : +
(one)
Ketone : Nitrite :-

Leucocyte
Sediment

Leucocyte
Eritrocyte
Epithelial
:+
Cylinder
Crystal
Bacteria
Others

:(-)
: 3-5
:1-2

::::-

Final
Diagnosis
33 years old, 7-8 weeks gravid

G4P3A0,
according to first day of last menstrual
period with hiperemesis gravidarum
and urinary tract infection