Name: Mrs.

M
Age: 21 yo
Adress: Batu Layar
Admitted: May, 9th 2012 at 21.20

TIME

SUBJECTIVE

09/05/
2012
21.20

Patient referred from Meninting

PHC with G1P0A0L0 S/L/IU 37
weeks head presentation with
mild preeclampsia. Patient
confessed abdominal pain that
spread to frank since 14.00
(09/05/12). History rupture of
membrane (-), bloody slim
(+),FM (+).
No history of nausea,
vomiting, headache, visual
disturbance and epigastric
pain.
No history of DM, HT, asthma.
LMP: forgot
History of ANC: >4x at
midwife and PHC
Last ANC: 30 April 2012, BP
was normal
History of USG: History of family planning:Next family planning: injecion
Obstetrical history:
1.This
Chronologist: -

OBJECTIVE
General status:
GC: well
BP: 140/100 mmHg
PR: 90 bpm
RR: 20
T: 35,9
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: 21 cm
EFW: 1860 g
UC: FHB: 12-12-12 (144 x/min)
VT: Lab:
HB: 12,3 g/dl
RBC: 4.47 M/dl
HCT: 37,7%
Kreatinin: 0,7
WBC: 11,61 K/dl
2,6
PLT: 230s K/dl

SGOT: 30
SGPT:24
Ureum:

ASSESTMENT

PLANNING

G1P0A0 L0 3738 wks/S/L/IU,

head
presentation
with severe
preeclampsia.

Obs mother & fetal

well being
CBC,HbSAg, UL,
SGOT, SGPT
MgSO4 40% 6 g in
RL 500 cc 28 tpm
Insert DC
DM co GP, advice:
- Therapy
conservative of
severe
preeclampsia
- Nifedipine 3x1
- Pro USG
- Observation

TIME
22.55

SUBJECTIVE
Patient confessed dizziness

OBJECTIVE
GC: well
BP: 130/80 mmHg
PR: 80 bpm
RR: 20
T: 36,1
UO: 100cc/1 hour
FHB: 8-6-7 (84 x/min)

10/05/
2012
00.00

GC: well
BP: 120/80 mmHg
PR: 80 bpm
RR: 22
T: 36,2
UO: 100cc/2 hour
FHB: 14-13-13 (160 x/min)

01.00

GC: well
BP: 120/80 mmHg
PR: 84 bpm
RR: 22
T: 36,1
UO: 100cc/3 hour
FHB: 13-13-13 (156 x/min)

02.00

GC: well
BP: 120/70 mmHg
PR: 82 bpm
RR: 20
T: 36,1
UO: 100cc/4 hour
FHB: 13-13-13 (156 x/min)

03.00

GC: well
BP: 120/80 mmHg
PR: 72 bpm
RR: 20
T: 36,1
UO: 100cc/4 hour

ASSESTMENT
G1P0A0 L0 37-38
wks/S/L/IU, head
presentation with
severe
preeclampsia +
susp IUGR

PLANNING
O2 5 lpm
Educate mother to
sideway to the left
Educate mother to
eat & drink
CTG
DM co GP, advice:
- IU resucitation
- CTG again 1 hour
later
MgSO4 40% 6 g in
RL 500 cc 28 tpm
(Flash II)
CTG
DM co GP, advice:
- Obs VS mother &
FHB

TIME

SUBJECTIVE

OBJECTIVE

04.00

GC: well
BP: 120/70 mmHg
PR: 80 bpm
RR: 20
T: 36,1
UO: 100cc/5 hour
FHB: 12-13-13 (152 x/min)

05.00

GC: well
BP: 120/80 mmHg
PR: 80 bpm
RR: 20
T: 36,2
UO: 500cc/7 hour
FHB: 13-12-12 (148 x/min)

08.00

Patient confessed dizziness

GC: well
BP: 130/80 mmHg
PR: 84 bpm
RR: 20
T: 36
UO: 700cc/8 hour
FHB: 12-12-12 (144 x/min)

09.00

13.00

ASSESTMENT

PLANNING

Stop O2s
Co GP, advice:
- CBC
USG
Co SPV, advice:
- CTG; if reactive,
conservative, but if
pathologic,
termination
CTG reactive
Co GP, advice:
- Therapy conservative
- Dexametason 10
mg/12 hours

Patient confessed dizziness

GC: well
BP: 120/90 mmHg
PR: 88 bpm
RR: 20
T: 36
UO: 700cc
FHB: 12-12-13 (148 x/min)

MgSO4 40% 6 g in RL
500 cc 28 tpm (Flash
III)

TIME

SUBJECTIVE

OBJECTIVE

14.00

GC: well
BP: 120/80 mmHg
PR: 80 bpm
RR: 20
T: 36,1
UO: 800cc
FHB: 12-12-13 (148 x/min)

20.00

GC: well
BP: 120/80 mmHg
PR: 84 bpm
RR: 20
T: 36,2
UO: 200cc/3 hours
FHB: 12-11-12 (140 x/min)

23.30

GC: well
BP: 120/90 mmHg
PR: 88 bpm
RR: 20
T: 36
FHB: 12-12-12 (144 x/min)

ASSESTMENT

PLANNING

MgSO4 40% 6 g in RL
500 cc 28 tpm (Flash
IV)
Dexametason 10
mg/12 hours