Name: Mrs. NE Age: 19 yo Address: Keruak Lotim RM: 049089 Admitted: June 2nd, 2012 at 10.

25

TIME 28/07/ 2012 14.20

SUBJECTIVE Patient referred from Selong GH with G1P0A0L0 28-29 weeks S/L/IU with eklampsia and MgSO4 refracter and EFW 1000 g. History of seizures 4X (1x at home and 3x at Selong GH. Abdominal pain (-), Bloody slim (), FM (+). No history of DM, HT, asthma. LMP: forgot EDD: History of ANC: 3x at PHC Last ANC: 20/07/12 result BP: 150/100 History of USG: History of family planning: Next family planning:Obstetrical history: I. This

OBJECTIVE General status: GCS: E3V3M4 BP: 150/100 mmHg PR: 88 bpm RR: 20 T: 36,5 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: head L2: back on the left side L3: breech L4:UFH: 21 cm EFW: 3100 g UC: FHB: 11-11-11 (132 x/min) VT: -

ASSESTMENT G1P0A0L0 P/S/L/IU breech 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: pregnant termination with misoprostol 50 mcg and drip MgSO4 40% 28 tpm.

TIME

SUBJECTIVE Chronologist: (20/07/2012) S: Patient referred from Keruak PHC with G1P0A0H0 preterm with PEB. LMP: EDD: O: BP: 170/120 mmHg PR: 80 bpm RR: 18 T: 36,7 Lab: HB: 13,4 g/dl WBC: 10,70 K/dl PLT: 236 K/dl Proteinuria: +2 GDS: 61 SGOT:25 SGPT:24 BUN:16 Serum kreatinin :0,7 P: Conservative MgSO4 Conservative traetment

OBJECTIVE Lab: Hb = 15,2 g/dl Rbc = 5,34 Leu = 22,01 Plt = 204 Hct = 45,2% HbSAg = (-) Protein urine : +3 GDS: 104 SC: 0,6 Ureum : 24 As. Urat: 5,3 SGOT : 37 SGPT : 36

ASSESTMENT

PLANNING

(26/07/2012) S:O: BP: 150/100 mmHg PR: 90 bpm RR: 20 T: 36,7 Proteinuria: +1

TIME

SUBJECTIVE (28/07/2012) At PHC S: Patient bring by family to Keruak PHC with seizures 1x at home O: BP: 180/110 mmHg PR: 90 bpm RR: 20 T: 36,7 Proteinuria: +3 At PKM seizures 3x ~ 15 minutes P: inj. MgSO4 4 g/iv Set inf.RL and insertion DC Inj. MgSO4 2 g/iv when siezures still seizures inj diazepam 10 g (28/07/2012) At Selong GH S: patient referred from PKM with G1P0A0L0 28-29 weeks S/L/IU with eklampsia. History of sizures >3x and history conservative treatment for 5 days. O: GCS: E3V4M5 BP: 160/110 mmHg PR: 96 bpm RR: 20 T: 36,5 Proteinuria: +2 TFU: 25 cm

OBJECTIVE

ASSESTMENT

PLANNING

TIME

SUBJECTIVE A: G1P0A0L0 28-29 weeks S/L/IU with eklampsia and refracter and MgSO4 and EFW 1000 g P: inj. MgSO4 4 g/iv Set inf.RL and insertion DC Inj. MgSO4 2 g/iv when siezures Drip diazepam 12 tpm 10 lpm

OBJECTIVE

ASSESTMENT

PLANNING

17.00

Patient confessed dizzines

GC: well BP: 160/100 mmHg PR: 90 bpm RR: 24 T: 36,7 GC: well BP: 170/130 mmHg PR: 88 bpm RR: 24 T: 36,7 UO: 50 cc/hour GC: well BP: 180/130 mmHg PR: 88 bpm RR: 24 T: 36,7 UO: 50 cc/hour

G1P0A0L0 P/S/L/IU breech presentation with eklampsia

Obs mother & fetal well being Insertion misoprostol 50 mcg/6 hour Obs mother & fetal well being

20.00

G1P0A0L0 P/S/L/IU breech presentation with eklampsia

23.00

G1P0A0L0 P/S/L/IU breech presentation with eklampsia

Obs mother & fetal well being Insertion misoprostol 50 mcg/6 hour Nifedipin 1 tab

TIME 17.30 -

SUBJECTIVE

OBJECTIVE GC: well BP: 160/120 mmHg PR: 88 bpm RR: 24 T: 36,7 UO: 40 cc/hour GC: well BP: 160/120 mmHg PR: 92 bpm RR: 24 T: 36,7 UO: 40 cc/hour Djj: 96x/minute GC: well BP: 150/120 mmHg PR: 88 bpm RR: 24 T: 36,7 UO: 60 cc/hour His: 2x10~35 DJJ: VT : 2cm, eff. 10 %, Amnion (+), breech palpable HI, denominator unclear, impalpable small part of fetal & umbilical cord. GC: well BP: 150/100 mmHg PR: 96 bpm RR: 24 T: 36,7 UO: 50 cc/hour DJJ: His : 4x10~40 teknusperjolvulka

ASSESTMENT G1P0A0L0 P/S/L/IU breech presentation with eklampsia

PLANNING Obs mother & fetal well being Nifedipine 10 mg/oral

18.00

G1P0A0L0 P/S/L/IU breech presentation with eklampsia and fetal bradikardi

DM co SPV SPV advice: KIE family

20.00

G1P0A0L0 P/S/D/IU breech presentation with eklampsia and laten phase 1st of labor

Observation mother well being Observed progress of labor Suggest mother to eat and drink

23.30

Mother want to bearing down

G1P0A0L0 P/S/D/IU breech presentation with eklampsia and 2nd stage of labor

Observed mother and baby well being Suggest mother to eat, and drink.

TIME 23.35 -

SUBJECTIVE -

OBJECTIVE -

ASSESTMENT

PLANNING Baby was born, spontan B, dead, male, AS 0, 1300 gram, 42 cm, Anus (+), congenital anomaly (-) Placenta was born spontaneus, not complete, bleeding 500cc Manual placenta amniotic membrane Oxitocin drip 20 IU Pro USG

(30/07/ 12) 01.35

GC: well Cons: CM BP: 150/100 HR: 84 bpm RR: 22 tpm T: 36,5 C UC: + UFH: 1 finger below umbilicus UO: 50 cc/hour AB: GC: well Cons: CM BP: 150/100 HR : 88k bpm RR : 20 tpm T : 36,4 C UFH : 2 finger below umbilicus UO: 60 cc/hour UC : + AB : -

2 hour post partum

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

19/05/ 2012 07.00

One day post partum