Case report

Name: Mrs.S
Age: 39 yo
Address: Bagek Kembar
Admitted: November, 13th 2012 at 10.10
wita

TIME

SUBJECTIVE

OBJECTIVE

ASSESTMENT

PLANNING

13-11-12
10.10

Patient reffered from Tanjung

Karang PHC with G3P1A1L1
37-38 weeks with severe
preeclampsia. Patient
confessed dyspneu since 0711-12. No history of nasusea,
vomiting, epigastric pain,
visual disturbance and seizure.
No history of DM, HT, asthma.

G3P1A1L1 40
weeks/ S/L/IU head
presentation with
severe preeclampsia
with+ pulmonary
edema + susp.IUGR

Observation mother
and fetal well being
DM announce to
SPV pro termination
and manage with
severe preeclampsia
therapy. SPV advice :
- manage with severe
preeclampsia therapy
and induction with
oxytocin and co to
SPV pulmonology

History of ANC: >4x at PHC

Last ANC:
Result : BP :

General status:
GC: well
BP: 200/120 mmHg
PR: 88 bpm
RR: 33 bpm T: 36,5oC
Eye : anemis (-/-), icteric (-/-)
Thorax :
Cor : S1S2 single reguler, murmur
(-), gallop (-)
Pulmo : vesikuler (+/+), wheezing
(-/-),
Ronkhi (+/+).
Abdomen : scar (-), striae (+), linea
nigra (+)
Extremity : edema (+/+), warm
acral (+/+)

History of USG: 1 X in NTB

GH
Last USG : 13-11-2012
Result : fetus S/L/IU
Placenta : fundus
Amnion : enough
BPD : 39w6d
AC : 34w4d
FL : 35w0d
EFW : 2131 gram
EDD : 22-12-12

Obstetrical status:
L1: breech
L2: back on the left side
L3: head
L4: 4/5
UFH: 29 cm
EFW: 2790 gr
UC: FHB: 12-12-12 (144x/min)
VT: 1 cm, eff 10 %, amnion (+),
head palpable HI

History of family planning:

Next family planning:

Pelvic Score : 5
Cervix dilatation 1 cm : 1
Cervix length 2 cm : 1
Station H1 : 1
Cervix consistency moderate : 1
Cervix position mid : 1

LMP: 06-02-2012
EDD: 13-11-2012

Obstetrical history:
I., preterm, TBA, 15 yo, live
II.Abortus
III.This

Therapy severe
Preeclampsia
Bolus MgSO4 4 gr/IV
Drip MgSO4 6 gr
Give nifedipin 10 mg
po
Insert DC
Give O2 4 lt/minutes

TIME

SUBJECTIVE

OBJECTIVE

Chronologist at Tanjung Karang PHC :

Lab Evaluation

(12-11-2012)

HB: 13,4 g/dl

HCT : 43,4 %
RBC: 4,96 M/dl
WBC: 10,8 K/dl
PLT: 266 K/dl
Creatinin : 0,8mgl/dl
Ureum : 23 mgl/dl
SGOT : 18 mgl/dl
SGPT : 11 mgl/dl
HbSAg: (-)
Proteinuria: + 3

S : patient conessed dyspneu and edema

ekstrimitas
O : GC : well
BP : 160/100 mmHg
PR : 80 bpm
RR : T : 37,0oC
L1 : breech
L2 : back on the left side
L3 : head
L4 : 4/5
UFH : 30 cm
FHB : +
UC : Lab :
Proteinuria : + 3
A : G3P1A1L1 37-38 weeks with severe
preeclampsia
P:
Reffered to NTB

ASSESSMENT

PLANNING

TIME

SUBJECTIVE

OBJECTIVE

11.00

Dyspneu

General status:
GC: well
BP: 210/130 mmHg
PR: 96 bpm
RR: 33 bpm T: 36,5oC

12.00

Dyspneu

General status:
GC: well
BP: 210/120 mmHg
PR: 96 bpm
RR: 33 bpm T: 36,5oC

13.00

Dyspneu

General status:
GC: well
BP: 210/130 mmHg
PR: 96 bpm
RR: 33 bpm T: 36,5oC

14.00

Dyspneu

General status:
GC: well
BP: 210/130 mmHg
PR: 96 bpm
RR: 33 bpm T: 36,5oC

15.00

Dyspneu

General status:
GC: well
BP: 210/130 mmHg
PR: 96 bpm
RR: 33 bpm T: 36,5oC

16.00

Dyspneu

General status:
GC: well
BP: 210/130 mmHg
PR: 96 bpm
RR: 33 bpm T: 36,5oC

17.00

Dyspneu

General status:
GC: well

ASSESTMENT

Give nifedipin 10 mg po

TIME

SUBJECTIVE

OBJECTIVE

11.00

Dyspneu

General status:
GC: well
BP: 210/130 mmHg
PR: 96 bpm
RR: 33 bpm T: 36,5oC

12.00

Dyspneu

General status:
GC: well
BP: 210/120 mmHg
PR: 96 bpm
RR: 33 bpm T: 36,5oC

13.00

Dyspneu

General status:
GC: well
BP: 210/130 mmHg
PR: 96 bpm
RR: 33 bpm T: 36,5oC

14.00

Dyspneu

General status:
GC: well
BP: 210/130 mmHg
PR: 96 bpm
RR: 33 bpm T: 36,5oC

15.00

Dyspneu

General status:
GC: well
BP: 210/130 mmHg
PR: 96 bpm
RR: 33 bpm T: 36,5oC

16.00

Dyspneu

General status:
GC: well
BP: 210/130 mmHg
PR: 96 bpm
RR: 33 bpm T: 36,5oC

17.00

Dyspneu

General status:
GC: well

ASSESTMENT

Give nifedipin 10 mg po