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M
Age: 21 yo
Adress: Batu Layar
Admitted: May, 9th 2012 at 21.20
TIME
SUBJECTIVE
09/05/
2012
21.20
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
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
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
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