Name: Mrs. N Age: 16 yo Address: Kr. Nangka RM: 061977 Admitted: October 20th, 2012 at 13.

00

TIME 20/10/ 2012 13.00

SUBJECTIVE Patient referred from Tanjung GH with G1P0A0L0 35 weeks S/L/IU with eklampsia. History of seizures 2X (2x at Tanjung GH). Patient referred nausea and vomiting. History rupture of membrane (-), Abdominal pain (), Bloody slim (-), FM (+). No history of DM, HT, asthma. LMP: forgot EDD: History of ANC: 4x at PHC Last ANC: 10/10/12 History of USG: History of family planning: Next family planning: injection 3 mounth Obstetrical history: I. This

OBJECTIVE General status: GCS: E4V5M6 BP: 160/100 mmHg PR: 100 bpm RR: 24 T: 36, Eye : palor (-), icteric (-) Thorax : Cor : S1S2 single reguler (murmur ), (gallop -) Pulmo : vesikuler (+/+), wheezing (/-), Ronkhi (-/-). Abdomen : scar (-), striae (+), linea nigra (+) Extremity : edema (+/+), warm acral (+/+) Obstetrical status: L1: breech L2: back on the right side L3: head L4: 5/5 UFH : 31 cm EFW : 3100 UC: 1 x 10 ~ 15 FHB: 13-13-13 VT: 1 cm, eff 25%, amnion (+), head presentation, denominator unclear, HI. Impalpable small part of fetal & umbilical cord

ASSESTMENT G1P0A0L0 A/S/L/IU head presentation with eklampsia

PLANNING Obs mother & fetal well being Cek DL, UL, HbSAg, BUN, uric acid, SC, SGOT, SGPT. O2 5 lpm DM co SPV, advice: Observation 2-3 hours co again pro CS

TIME

SUBJECTIVE Chronologist: (20/10/2012) 09.00 S: Patient pregnant 35 weeks, came to PHC reffered nausea, vomiting, blurred vision, headache since overnight LMP: 14/02/2012 ? EDD: 21/22/2012 ? O: BP: 180/130 mmHg PR: 94 bpm RR: 24 UFH : 3 fingers below the processus xipoideus EFW : 3565 UC: FHB: 134 Lab: Proteinuria: +3 A: G1P0A0L0 35 weeks/S/L/IU severe preeclampsia P: IVFD RL 20 tpm

OBJECTIVE Lab: Hb = 10,9 g/dl Rbc = 4,59 WBC = 19,7 Plt = 296 Hct = 36,1 % HbSAg = (-) Protein urine : +3 SC: 0,8 Ureum : 31 As. Urat: 5,3 SGOT : 37 SGPT : 36

ASSESTMENT

PLANNING

TIME

SUBJECTIVE

OBJECTIVE

ASSESTMENT

PLANNING

(20/10/2012) At Tanjung GH 10.00 WITA S: Patient referred from Tanjung PHC with G1P0A0L0 35 weeks S/L/IU with severe preeclampsia, patient reffered nausea, vomiting, headache, blurred vision, first pregnancy, extremity edema.
O: BP: 170/130 mmHg PR: 82 bpm T: 36 LMP : 14/02/2012 UFH : 32 cm L1: breech L2: back on the right side L3: head L4: 5/5 FHB: 12-12-11 (140 bpm) A: G1P0A0L0 35 weeks/S/L/IU head presentation with severe preeclampsia P: Drip MgSO4 16 g (15 cc) in RL 28 tpm Nifedipin tab 10 mg Insert DC

TIME

SUBJECTIVE 10.15 WITA S: patient suddenly seizure 2 times. O: BP: 150/100 mmHg PR: 84 bpm T: 37,2 FHB: 12-12-12 patellar reflex : +/+ Lab: Protein: +3 Hb : 10,0 gr% A: G1P0A0L0 35 weeks/S/L/IU head presentation with eclapsia P: Bolus MgSO4 4 g in 10 cc aquadest IV Refer to NTB GH

OBJECTIVE

ASSESTMENT

PLANNING

TIME 13.30

SUBJECTIVE patient suddenly seizure

OBJECTIVE GCS : E4V5M6 BP : 160/100 mmHg PR : 102 bpm FHB : 11-11-12 GC: well BP: 160/100 mmHg PR: 90 bpm RR: 24 T: 36,8 UC :1 x 10 ~ 15 BP : 150/100 mmHg FHB : 12-12-13

ASSESTMENT

PLANNING Bolus MgSO4 2 gram Co SPV : 2-3 hours of observation report back to SC

16.00

Patient confessed dizzines

G1P0A0L0 A/S/L/IU head presentation with eklampsia

DM co SPV again Pro SC. SPV Acc SC at 22.00 WITA

20.00

G1P0A0L0 A/S/L/IU head presentation with eklampsia

Prepare SC o skin tes ampi (-) Inj ampi 2 g IV CS began Baby was born, male, 2400 gram, AS 5-7. Anus (+), congenital anomaly (-), Placenta was born. Manually. Complete. Bleeding 300cc

23.00

21/10/ 2012 01.00

Patient confessed delivery wound pain

BP: 130/90 HR : 88 bpm RR : 20 tpm T : 36,6 C UFH : 1 finger below umbilicus UC : + Lochia rubra: OU : 500 cc

2 hours post SC

Observe mother well being KIE mother to take a rest

TIME 08.00 21/10/ 2012 -

SUBJECTIVE

OBJECTIVE GC: well Cons: CM BP: 150/100 HR : 88k bpm RR : 20 tpm T : 36,4 C UFH : 2 finger below umbilicus UO: 700 cc UC : +

ASSESTMENT One day post SC

PLANNING Observed well being Suggest mother to mobilisation, eat, and drink, medication Supression lactation

Baby in NICU: PR:148 RR: 52 T: 36,4