Name: Mrs.

N
Age: 16 yo
Address: Kr. Nangka
RM: 061977
Admitted: October 20th, 2012 at 13.00

TIME

SUBJECTIVE

OBJECTIVE

20/10/
2012
13.00

Patient referred from Tanjung

GH with G1P0A0L0 35 weeks
S/L/IU with eklampsia.
History of seizures 2X (2x at
Tanjung GH). Patient
complaint nausea and
vomiting. History rupture of
membrane (-), Abdominal
pain (-), Bloody slim (-), FM
(+).
No history of DM, HT,
asthma.

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 (+/+)

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

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: -

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 complaint 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
(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
complaint 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

OBJECTIVE

ASSESTMENT

PLANNING

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

SUBJECTIVE

OBJECTIVE

ASSESTMENT

PLANNING

13.30

patient suddenly seizure

GCS : E4V5M6
BP : 160/100 mmHg
PR : 102 bpm
FHB : 11-11-12

Bolus MgSO4 2 gram

Co SPV :
2-3 hours of
observation report
back to SC

16.00

Patient confessed dizzines

GC: well
BP: 160/100 mmHg
PR: 90 bpm
RR: 24
T: 36,8
UC :1 x 10 ~ 15

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

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

20.00

BP : 150/100 mmHg
FHB : 12-12-13

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

Prepare SC
o skin tes ampi (-)
Inj ampi 2 g IV

23.00

CS began
Baby was born, male,
2400 gram, AS 5-7.
Anus (+), congenital
anomaly (-),
Placenta was born.
Manually. Complete.
Bleeding 300cc

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:

2 hours post SC

Observe mother well

being
KIE mother to take a
rest

TIME
08.00
21/10/
2012

SUBJECTIVE
-

OBJECTIVE
GC: well
BP: 150/100

Cons: CM
HR : 88k bpm

RR : 20 tpm
T : 36,4 C
UFH : 2 finger below
umbilicus
UO: 700 cc
UC : +
Baby in NICU:
PR:148
RR: 52
T: 36,4

ASSESTMENT
One day post SC

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