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MEMBERS OF THE GROUP:

PUTU ANNA ARTHA RAHAYU P07124214 014


KADEK ARI DWI LESTARI PO7124214 015
I G.A.A CAHYANINGRUM ANANTA P07124214 017
KADEK DEVI ARY SUTA P07124214 022
NI KOMANG NGURAH APNI S SJ P07124214 028
KADEK VEBNY LIA PRIMANTARI P07124214 040
KADEK ARDI MAHAYANI P07124214 053
NI KADEK SATRYANING AYU P07124214 054
CASE
Date : Friday, October 13th 2017
Time : 11.20 am
Place : OPD Siloam Hospital Bali
A. SUBJECTIVE DATA
1. Identity
Patient Husband
Name : Mrs. KSA Mr. PM
Age : 29th years old 30th years old
Nationality : Indonesia Indonesia
Religion : Hindu Hindu
Education : Senior High School Senior High School
Occupation : Unemployed Entrepreneur
Phone : 081999096xxx
Address : Pulau Moyo Street No 1, South Denpasar
2. Chief Complaint
A patient came to the hospital for the second check up routine during
pregnancy, she complained that she often felt tired and pain in the back, but
sometimes she felt cramps in abdominal as well. Abdominal cramp was felt
when she suddenly stood up after sit down for along time. She said when
tired, she usually massage her back in beauty salon.

3. Menstrual History
Menarche : 14 years old
Menstrual cycle : 28 days
Period : 5 days
Amount of blood : 3 times replace the pads/days
Complaint : none
4. History of Pregnancy, Delivery and Puerperium
I. 5th years old/Female/Clinic/Normal/Birth weight: 3000 grams /Life
II. 4th years old/Female /Clinic/Normal/Birth weight: 3000 grams/Life
III. This pregnant

5. Present Pregnancy History


First day of last menstruation : 7-7-2017 EDD: 14-4-2018
Her last ANC once in Siloam Hospital Bali with dr. Sp.OG on Wednesday , September
13th 2017.
TT : 5 times (complete)
History of Contraception : Never use any contraception
Contraception Plans : Tubectomy

6. History of health/ disease that has suffered now and then


Hypertension : None
Diabetes : None
Hepatitis : None
Tuberculosis : None
Asthma : None
Twins history : None
Others : None
Drugs Allergic History : None
8. Biological Needs History
7. History of Psycho-social a. Nutrition
Marital status: During Pregnancy
Dietary habit: one plate of rice, one piece of
Married lawfully 1 time chicken, and a small bowl of vegetables
for 7 years Frequency : 3 times a day
Last meal : 07.30 am (type of foods: bread)
Decision-making: Drinking pattern: mineral water around 7
Together glasses/day
Last drink : 11.10 am
Family support: Complaint : none
All families support this
b. Elimination
pregnancy Urinate
Workload: During Pregnancy
Frequency : more than 6 times a day
Mom does her job as Colour : yellow
housewife by doing Complaint : none
sweeping and cooking Last urinate : 07.30 am
Defecation
Healthy living habits: During Pregnancy
She said never smokes, Frequency : 1 time a day
Consistency : mushy
drinks and drugs Complaint : none
OBJECTIVE DATA
Assessment on Friday, October 13th 2017 at 11.25 WITA
1. General Inspection
 General Condition: good
 Awareness: compos mentis
 Emotional state: stable
 Body weight : 91 kg (before pregnancy: 88 kg (july 2017))
 Body height : 159 cm
 IMT: 35,99 kg/m2
Vital sign
 Blood pressure : 100/60 mmHg
 Pulse : 80x/mnt
 Temperature: 36,4 OC
 Respiration: 20 x/ mnt
2. Physical Data

Head : Clean hair, black hair color, Breast : symmetrical breast


no lesions, no dandruff and shape, prominent
no bumps. nipple, cleanliness
Face : No abnormalities. awake, and no breast
Nose : Symmetrical, clean no abnormalities.
visible secret. Abdomen : no surgical scar.
Eyes : Pink conjunctiva and white
Extremities
sclera.
Mouth : Moist mucosa, no caries and Hands: no odema. Pink
fresh lips. fingernails.
Neck : No abnormality, no swollen Feet : symmetrical, odema
lymph nodes, no jugular and no varicose
venous dam, no enlarged veins. Pink
thyroid gland. fingernails.Positive
left and right patellar
reflexes.
ANALISA
Diagnose:
Mrs.KSA 29 years old G3P2A0 gestasional age 13
week 6 days with obesity
Problem :
1. Mrs.KSA has back pain
2. Mrs. KSA has cramps in the lower abdomen
3. Mrs. KSA doesn’t know about necessary of rest
during pregnancy
4. Mrs. KSA doesn’t know about nutrition during
pregnancy
PENATALAKSANAAN

Date October 13th 2017, Time: 11.45 PM in OPD Room Siloam Hospital
1. Explaining to Mrs.KSA and her husband about vital sign examination
result, Mrs.KSA and her husband understand the explanation.
2. Explaining to Mrs.KSA and her husband, about :
 Causes and ways of treating back pain, Causes and ways of
treating cramps in the lower abdomen, Patient already understand
and willing to follow the doctor or midwife’s advice.
 Necessary of rest during 2rd trimester in pregnancy. Patient
already understand and willing to follow the doctor midwife’s
advice.
 Nutrition during 2rd trimester in pregnancy, Patient already
understand and willing to follow the doctor or midwife’s advice.
Observe the explanation of an obstetrician in scheduling a return visit

3. Collaborate with the obstetricians to ultrasound examination and


explaining the result. Ultrasound examination on 13th October 2017 at
12.10 PM have done by obstetricians with the result:
Interpretation :
GA = 13 w + 6 D
EFW = 799 gr
Patient already understand about the result
4. Observe the obstetrician’s explanation about how to used the medicine,
such as :
FE+Vit C 1x400mg (XXX) . Patient already understand about the
explanation.
4. Observe the ocbstetrician explanation and scheduling for return visit on
13th November 2017 or if patient have complaint. Patient already
understand and willing to follow the doctor’s advice

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