CASE

Name : Mrs. M
Age : 41 yo
Address : Lingsar
Admitted: July, 16th 2016
MR : 579556

TIME

SUBJECTIVE

OBJECTIVE

ASSESTMENT

PLANNING

16/06/16
(18.00)

Patient come to NTB GH referred

from Praya GH with G1P0A0H0
A/S/L/IU with Severe Preeclampsia +
Hypertiroid + elderly primigravida +
Sinus Tachycardia. Patient confessed
abdominal pain since 21.00
(15/06/16), Bloody slime (+) since
22.00 (15/06/16), FM (+), water leaked
out from her womb (-). Patient
Palpitation (+), sweating (-), tremor
(-), weakness (-), Defecation and
urination in normal range.
History of Hypertiroid (+) since 17
yo, HT (+) since 4 year ago, DM (-),
asthma (-) allergy (-)
History of family (-)

General status :
GC : well
Consciousness : CM
BP : 180/110 mmHg
PR : 100 bpm
RR : 31 rpm
T : 36,50C

G1P0A0L0 41-42
weeks S/L/IU head
presentation with
Cronic Hypertension
+ Hyperthyroidism +
elderly primigravida
+ inpartu latent
phase first stage of
labor

DM Planning
Diagnostic
CBC
UL
CTG
HbsAg
ECG
FT4, TSH

History of medication: PTU and

propanolol.
History of Allergy: (-)
LMP : 01/09/2015
EDD : 06/06/2016
GW: 41-42 weeks
ANC history : 8x at PHC
Last ANC : 10/06/2016
Result : BP 140/70 mmHg, BW: 47kg,
UFH: 28 cm, head presentation.
USG history : 1x at SPOG
Last : 13/03/16
Result : G1P0A0 uk. 32 minggu
T/H/IU
+ hipertiroid + HDK + Primi tua primer
Family planning history :-

Local Status
Eye : pale (-/-), icteric (-/-),
exofthalmus (+)
Cor : S1S2 single regular,
murmur (-), gallop (-)
Pulmo : vesicular (+/+), ronchi
(-/-), wheezing (-/-)
Abdomen : striae gravidarum (-),
scar (-)
Extremity : edema (-/-), warm
acral (+/+), tremor (-/-)
Obstetrical Status
L1 : breech
L2 : back on the right side
L3 : head
L4 : 4/5
UFH : 31 cm
EFW : 3100 gram
UC : 2x10~30
FHR : 11-12-11 (136 bpm)
VT : 3 cm, eff 25%, amnion (+)
head presentation, H1,
denominator ROA, not palpable
small part & umbilical cord

Therapy
Observation
progress of labor
Observe mother &
fetal well being
Suggest mother to
eat and drink
Suggest mother to
lay to to the left side.
CIE : CIE mother
and family about
planning
Pro consul interna
DM co to GP, GP co
to SPV, advice :
Observation
Progress of labor
Nifedipine 3 x 10
mg

TIME

SUBJECTIVE
Obstetric History:
1. Ini

OBJECTIVE
Pelvic Examination
Promontorium unpalpable
Spina ischiadica not prominent
Os sacrum convex
Os coccygeus mobile
Arcus pubis > 90
Laboratory (02/05/2016):
HB: 13.9 g/dl
RBC: 4,86 (10^6/uL)
HCT: 41,0 %
WBC: 9,17 (10^3/uL)
PLT: 293 (10^3/uL)
Ureum : 14
Cr: 0,6
SGOT: 49
SGPT: 46
HbsAg: non reactive

ASSESSMENT

PLANNING

TIME

SUBJECTIVE

16/06/2016

Chronology at Praya GH
(16/06/2016)
S:
Patient referred from Langko PHC
with G1P0A0 A/T/H + Hyperthyroid.
Patient confess abdominal pain
referred to flank since 17.00
(15/06/16). Water leaked out from
her womb (-).
O:
GC : moderate
Consciousness : CM
BP : 160/100 mmHg
PR: 80 bpm
RR: 20 tpm
Obstetric status
UFH: 27 cm
FHB : 144 bpm
VT : 3 cm, eff 50%, amnion (+)
head presentation, H II.
A:
G1P0A0L0 A/S/L with severe
preeclampsia + Hyperthyroid + PTP
+synus tachicardy
P:
IVFD RL + MgSO4 40% 20 dpm
Bolus MgSO4 20% 4gr

OBJECTIVE

ASSESSMENT

PLANNING

Time

Subject

Object

Assessment

Planning

22.00

Abdominal pain (+++),

FM (+)

General status
GC : well
BP : 180/110 mmHg
PR: 100 tpm
RR: 20 tpm
T: 36,5C
UC : 3x10~35
FHB : 11-12-11
VT : 4 cm, eff 50%, amnion (+) head
presentation, H1, denominator ROA, not
palpable small part & umbilical cord

Active phase first

stage of labor

Observation Progress
of labor with WHO
partograph

17/06/1
6
02.00

Abdominal pain (++),

FM (+)

General status
GC : well
BP : 170/100 mmHg
PR: 104 tpm
RR: 20 tpm
T: 36,5C
UC : 3x10~35
FHB : 12-12-12
VT : 6 cm, eff 50%, amnion (+) head
presentation, H1, denominator ROA, not
palpable small part & umbilical cord

Protracted active
phase first stage of
labor

DM planning:
Observation Progress
of labor with WHO
partograph

General status
GC : well
BP : 170/90 mmHg
PR: 96 tpm
RR: 20 tpm
T: 36,5C
UC : 3x10~35
FHB : 12-12-12
VT : 6 cm, eff 50%, amnion (+) head
presentation, H1, denominator ROA, not
palpable small part & umbilical cord

Arrested active
phase first stage of
labor

06.00

Abdominal pain (++),

FM (+)

DM co to GP, GP co to
SPV, SPV advice:
Observation, if there is
no progress, pro Csection

DM Planning:
Amniotomy
DM co to GP, GP co to
SPV, SPV advice:
Pro C section