Case Case 22G4P3, 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

Chief complaintNausea and vomiting accompanied by headache since 2 months before admissions.

History of Present IllnessPatient 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

AnamnesisAnamnesis

History of Past Illness•History of hypertension : denied•History of diabetes mellitus : denied•History of allergy : denied•History of epilepsy : denied•History of hematologic disease : denied•History of urinary tract/kidney disease : denied•History of trauma : denied•History of surgery : denied•History of cronic infection : denied•Antenatal Care : twice (midwife and doctor)

• 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 : compos mentis•Vital Signs– Blood pressure : 120/70 mmHg–Heart rate : 80x/minutes– 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)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 : 11,1 g/dl–Hematocrit : 32%–Leucocyte : 5.400/uL–Trombocyte : 197.000/uL–Blood type : O+–HbsAg : -

Laboratory examinationLaboratory examination

• Urine Analysis–Glucose :-– Protein :-– Bilirubine :-– Urobilinogen :-– pH :7.5–Density

:1015–Occult blood :

+(one)– Ketone :-– Nitrite :-

• Leucocyte:+++(three)

• Sediment– Leucocyte :18-20– Eritrocyte :1-2– Epithelial :+– Cylinder :-– Crystal :-– Bacteria :-–Others :-

Working diagnosisG4P3, 33 years old, 7-8 weeks gravid according to first day of last menstrual period with hiperemesis gravidarum and urinary tract infection

 Planning1.Cefotaxime 3x1g IV2.Primperan 3x1 ampoules drip IV3.Neurobion 1 ampoules drip IV4.Ranitidin 2x1 ampoules drip IV5.IVF Futrolit 1500cc/24 hours  

FOLLOW UPFOLLOW UP

Date Subjective Objective Assesment Planning

9th of June 2015

Nausea (-), Vomiting (-), headache (+) defecation (-), void (+), complains felt better than yesterday.

General condition

: moderately ill

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

1. Repeat urine analysis 24 hour after antibiotics given

05.00 am

Level of consciousness

: Compos mentis

2. Cefotaxime 3x1g IV

 Vital signs

4.Neurobion 1 ampoules drip IV

 

o   Blood pressure

: 110/70 mmHg

5. Ranitidin 2x1 ampoules drip IV

 

o   Heart rate

: 90x/minutes 6. IVF Futrolit 1500cc/24 hours

 

o  

Respiratory rate

: 23x/minutes

7.Primperan 3x1 ampoules drip IV

 

o   Body temperature

: 36.7°C 

Physical Examination

Palpable hepatomegaly

Date Subjective Objective Assesment Planning10th of June 2015

Nausea (-), Vomiting (-), headache (-) defecation (+), void (+)

General condition

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

- Patient Discharged

05.00 am

Level of consciousness

: Compos mentis

Cefotaxime ->

Cefadroxi l3x500mg

po

 Vital signs

Primperan IV -> 3x10mg po

 

o   Blood pressure

: 110/60 mmHg

Stop ranitidine

 

o   Heart rate

: 64x/minutes Stop Neurobion

 

o  

Respiratory rate

: 20x/minutes Aff IVF

 

o   Body temperature

: 36.3°C  Control in 1 week

Physical Examination

Palpable hepatomegaly

Laboratory examinationLaboratory examination(10 June 2015)(10 June 2015)• Urine Analysis– Glucose :-– Protein :-– Bilirubine :-– Urobilinogen : (+)– pH :8.5– Density :

<1005– Occult blood : +(one)– Ketone :-– Nitrite :-

• Leucocyte :(-)• Sediment– Leucocyte : 3-5– Eritrocyte :1-2– Epithelial :

+– Cylinder :-– Crystal :-– Bacteria :-– Others :-

G4P 3A0, 33 years old, 7-8 weeks gravid according to first day of last menstrual period with hiperemesis gravidarum and urinary tract infection

Final Diagnosis