eklamsi 20-10-2012

Name: Mrs. NAge: 16 yoAddress: Kr. NangkaRM: 061977Admitted: October 20th, 2012 at 13.00

Name: Mrs. NAge: 16 yoAddress: Kr. NangkaRM: 061977Admitted: October 20th, 2012 at 13.00

TIME SUBJECTIVE OBJECTIVE ASSESTMENT PLANNING

20/10/201213.00

Patient referred from Tanjung GH with G1P0A0L0 35 weeks S/L/IU with eklampsia. History of seizures 2X (2x at Tanjung GH). Patient referred nausea and vomiting. History rupture of membrane (-), Abdominal pain (-), Bloody slim (-), FM (+).No history of DM, HT, asthma.

LMP: forgotEDD: -

History of ANC: 4x at PHCLast ANC: 10/10/12History of USG: -

History of family planning: -Next family planning: injection 3 mounth

Obstetrical history:I.This

General status:GCS: E4V5M6BP: 160/100 mmHgPR: 100 bpmRR: 24 T: 36,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: breechL2: back on the right sideL3: headL4: 5/5UFH : 31 cmEFW : 3100UC: 1 x 10’ ~ 15”FHB: 13-13-13VT: Ø 1 cm, eff 25%, amnion (+), head presentation, denominator unclear, ↓ HI. Impalpable small part of fetal & umbilical cord

G1P0A0L0 A/S/L/IU head presentation with eklampsia

•Obs mother & fetal well being• Cek DL, UL, HbSAg, BUN, uric acid, SC, SGOT, SGPT.•O2 5 lpm•DM co SPV, advice:Observation 2-3 hours co again pro CS


Chronologist:(20/10/2012) 09.00S:Patient pregnant 35 weeks, came to

PHC reffered nausea, vomiting, blurred vision, headache since overnight

LMP: 14/02/2012 ?EDD: 21/22/2012 ?

O:BP: 180/130 mmHgPR: 94 bpmRR: 24 UFH : 3 fingers below the processus

xipoideusEFW : 3565UC: -FHB: 134

Lab:Proteinuria: +3A:G1P0A0L0 35 weeks/S/L/IU severe

preeclampsia

P:• IVFD RL 20 tpm

Lab:Hb = 10,9 g/dlRbc = 4,59WBC = 19,7Plt = 296Hct = 36,1 %HbSAg = (-)Protein urine : +3SC: 0,8Ureum : 31As. Urat: 5,3SGOT : 37SGPT : 36


(20/10/2012) At Tanjung GH 10.00 WITAS: Patient referred from Tanjung PHC with G1P0A0L0 35 weeks S/L/IU with severe preeclampsia, patient reffered nausea, vomiting, headache, blurred vision, first pregnancy, extremity edema.

O:BP: 170/130 mmHgPR: 82 bpmT: 36LMP : 14/02/2012UFH : 32 cmL1: breechL2: back on the right sideL3: headL4: 5/5FHB: 12-12-11 (140 bpm)

A:G1P0A0L0 35 weeks/S/L/IU head presentation with severe preeclampsiaP:• Drip MgSO4 16 g (15 cc) in RL 28 tpm• Nifedipin tab 10 mg• Insert DC


10.15 WITAS: patient suddenly seizure 2 times.

O:BP: 150/100 mmHgPR: 84 bpmT: 37,2FHB: 12-12-12patellar reflex : +/+

Lab:Protein: +3Hb : 10,0 gr%

A:G1P0A0L0 35 weeks/S/L/IU head presentation with eclapsiaP:• Bolus MgSO4 4 g in 10 cc aquadest IV

• Refer to NTB GH


13.30 patient suddenly seizure GCS : E4V5M6BP : 160/100 mmHgPR : 102 bpmFHB : 11-11-12

Bolus MgSO4 2 gramCo SPV : 2-3 hours of observation report back to SC

16.00 Patient confessed dizzines GC: wellBP: 160/100 mmHgPR: 90 bpmRR: 24 T: 36,8UC :1 x 10’ ~ 15”


•DM co SPV again Pro SC.•SPV Acc SC at 22.00 WITA

20.00 - BP : 150/100 mmHgFHB : 12-12-13


• Prepare SCo skin tes ampi (-) Inj ampi 2 g IV

23.00 - CS beganBaby was born, male, 2400 gram, AS 5-7. Anus (+), congenital anomaly (-),

Placenta was born. Manually. Complete.Bleeding ± 300cc

21/10/201201.00

Patient confessed delivery wound pain

BP: 130/90 HR : 88 bpm RR : 20 tpm T : 36,6 CUFH : 1 finger below umbilicusUC : +Lochia rubra: OU : ± 500 cc

2 hours post SC Observe mother well beingKIE mother to take a rest


08.0021/10/2012

- GC: well Cons: CMBP: 150/100 HR : 88k bpm RR : 20 tpm T : 36,4 CUFH : 2 finger below umbilicusUO: ± 700 ccUC : +

Baby in NICU:PR:148RR: 52T: 36,4

One day post SC •Observed well being• Suggest mother to mobilisation, eat, and drink, medication• Supression lactation

eklamsi 20-10-2012

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