Name: Mrs.
S
Age: 35 yo
Address: Sekarbela
Admitted: July 2nd, 2012 at 23.00
TIME
SUBJECTIVE
02/07/
2012
23.00
Patient reffered from
Narmada PHC with G3P2A0L2
35-26 weeks S/L/IU head
presentation with susp
severe preeclampsi. Patient
confesed headache since
06.00 ( 2/7/12) blured vision
since 07.00 ( 2/7/12) and
nausea. Abdominal pain (-),
history rupture of membrane
(-) Bloody slim (-), FM (+).
No history of DM, HT,
asthma.
LMP: 30/10/2011
EDD: 6/08/2012
History of ANC: >4x at
Posyandu & PHC.
Last ANC: 04/06/2012Result:
normal
History of USG: History of family planning:
Injection 3 months
Next family planning:
Injection 3 months
Obstetrical history:
I. ,aterm, spontan,TBA,
13 yo, L
II. , aterm, spontan, midwive, 8
yo, L
III. this
OBJECTIVE
General status:
GC: moderate
GCS:E4V5M6
BP: 180/140 mmHg
PR: 100 bpm
RR: 24
T: 36,5
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 left side
L3: head
L4: 5/5
UFH: 26 cm
EFW: 2170 g
UC: 4x10-20
FHB: 11-12-13 (144 x/min)
VT: 3 cm, eff 25%, amnion
(+), head palpable HI,
denominator unclear impalpable
small part / umbilical cord.
ASSESTMENT
PLANNING
G3P2A0L2 35
weeks S/L/IU
with latent
phase 1st of
labor severe
preeclampsia +
impending
eclamsia +
HELLP
syndrome
Obs mother & fetal
well being
DM co GP: pro
obsevation
progrsive of labor,
advice:
- Continued therapy
MgS04 40% 4 g
bolus 10 cc, and
drip MgSo4 40% 6
g
- Nifedipine 3x1
TIME
SUBJECTIVE
OBJECTIVE
Lab:
HB: 13,9 g/dl
RBC: 4,67 M/dl
WBC: 10,43 K/dl
PLT: 188
HbSAg: (-)
Protein urine : +2
SC: 0,9
Ureum : 23
Uric acid: 3,8
SGOT : 281
SGPT : 333
Albumin 3,2
2/07/2
012
Patient come to Narmada PHC with 8
month pregnancy confessed tension
headache since this morning. Blured
vision (+), epigastric pain (-). Patien
wes cheked her blood presure at
polindes and she get 2 tablet of
captopril from midwive.
LMP: 30/10/2011
EDD: 6/08/2012
Obstetrical history:
I. ,aterm, spontan,TBA, 13 yo, L
II. , aterm, spontan, midwive, 8 yo, L
III. This
O:
GC: moderate
GCS:E4V5M6
BP: 190/140 mmHg
PR: 72 bpm
RR: 20
T: 35,8
ASSESTMENT
PLANNING
TIME
SUBJECTIVE
Obstetrical status:
L1: breech
L2: back on the left side
L3: head
L4: 4/5
UFH: 30 cm
EFW: 2945 g
UC: FHB: 12-12-12 (144 x/min)
VT: not done
Proteinuria: +++
G3P2A0L2 35 weeks S/L/IU
with susp severe
preeclampsia
Advise GP:
Insert DC (21.30)
MgS04 40% 4 g bolus (22.00)
Drip MgSo4 40% 6 g
Nifedipine 10 mg
OBJECTIVE
ASSESTMENT
PLANNING
TIM
E
3/07
/201
2
03.0
0
SUBJECTIVE
-
OBJECTIVE
ASSESTMENT
GC: moderate
GCS:E4V5M6
BP: 200/130 mmHg
PR: 88 bpm
RR: 24
T: 36,5
UC: 2x10-20
FHB: 144 bpm
VT: 3 cm, eff 25%, amnion
(+), head palpable HI,
denominator unclear impalpable
small part / umbilical cord.
G3P2A0L2 35
weeks S/L/IU
with latent
phase 1st of
labor severe
preeclampsia +
impending
eclamsia +
HELLP
syndrome
PLANNING
Co to GP:
methyldopa 1
tablet
Mother want to bearing down
Doranteknusperjolvulka
04.2
5
04.3
0
G3P2A0L2 35
weeks S/L/IU
with 2nd stage of
labor, severe
preeclampsia +
impending
eclamsia +
HELLP
syndrome
Observ. Mother and
fetal well being
Conduct mother to
bearing down
Baby was born,
male, AS 7-9, 2250
gram, 49 cm, Ballard
score: 34 (37-38
weeks) Anus (+),
congenital anomaly
(-)
Placenta was born
spontaneous,
complete, bleeding
250cc
TIME
06.30
SUBJECTIVE
Patien confessed headache
and nause
OBJECTIVE
GC: moderate
GCS:E4V5M6
BP: 160/120 mmHg
PR: 86 bpm
RR: 24
T: 36,5
UFH: 2 finger bellow the
umbilicus
UC: + good
Lochea: rubra + 45 cc
UO: 700 cc
ASSESTMENT
4th stage of
labor
PLANNING
CIE to feed and
drunk
Baby in NICU
PR:144
RR: 46
T: 36,4
09.30
Patien convultion
GC: bad
GCS:E3V3M6
BP: 200/160 mmHg
PR: 104 bpm
RR: 24
T: 36,5
UFH: 2 finger bellow the
umbilicus
UC: + good
Eclampsia
Puerperium
MgS04 40% 4 g
bolus 10 cc
O2 set
Co to SPV:
MgS04 40% 2 g
bolus 10 cc
If bad condition
reffered to ICU
10.00
12.00
Co. to dr. Sp.
Anesthesi
O2 masker 7Lpm
Patien convultion again
GC: bad
GCS:E3V3M6
BP: 240/170 mmHg
PR: 128 bpm
RR: 32
T: 36,5
UFH: 2 finger bellow the
umbilicus
Co. to SPV:
IV Inj. Diazepam 1
amp
Co.to dr. Sp.
Anesthesi
Reffered to ICU
TIME
SUBJECTIVE
OBJECTIVE
12.30
Consiousnes:somnolen
BP: 190/140 mmHg
PR: 130 bpm
RR: 32
T: 36,9
UO: -
14.00
Consiousnes:somnolen
BP: 180/130 mmHg
PR: 101 bpm
RR: 32
T: 36,1
UO: -
16.00
Consiousnes:somnolen
BP: 160/120 mmHg
PR: 136 bpm
RR: 27
T: 36,6
UO: -
18.00
Consiousnes:somnolen
BP: 180/140 mmHg
PR: 130 bpm
RR: 32
T: 36,9
UO: 10 cc
20.00
Consiousnes:somnolen
BP: 200/140 mmHg
PR: 130 bpm
RR: 32
T: 36,9
UO: 10 cc
ASSESTMENT
PLANNING
TIME
SUBJECTIVE
OBJECTIVE
23.30
Consiousnes:somnolen
GCS:
BP: 170/130 mmHg
PR: 114 bpm
RR: 32
T: 36,9
UO: 10 cc
04/06/
2012
01.30
convultion
Consiousnes:somnolen
GCS:
BP: 160/130 mmHg
PR: 120 bpm
RR: 24
T: 36,9
UO: 20 cc
06.00
Consiousnes:somnolen
GCS:
BP: 180/130 mmHg
PR: 130 bpm
RR: 32
T: 36,6
UO: 50
09.00
ASSESTMENT
PLANNING
IV Inj. Diazepam 1
amp
