Case 3

Name : Mrs. M
Age : 23 yo
Address : lingsar, Lombok Barat
Admitted : 6 July 2017
RM : 594222
TIME SUBJECTIVE OBJECTIVE ASSESSMENT PLANNING

9/7/20 Patient referred from PHC Lingsar General status G1P0A0L0 35-36 DM planning:
17 with G1P0A0L0 35 wk S/L/IU head GC: well weeks S/L/IU head Diagnostic:
21.00 presentation +PEB. Patient GCS : E4V5M6 presentation +PEB HbsAg
confessed nothing now. Bloody slime BP : 160/100 mmHg SGOT
(-), abdominal pain -. Water leaked HR: 86 tpm SGPT
from her womb (-) fetal movement RR: 20 tpm
(+). Dizzy (-), headache (-), epigastric Tax: 36.3 C Therapy:
pain (-), nausea (-), vomiting (-), MgSO4 40% 15
blurry vision (-). Localis status ml drip 1 g/hour
Eye : edema palpebra (-/-), an in 500 cc RL until
History of DM (-), HT (-), asthma (-), (-/-), ict (-/-) 24 hours post
allergic (-) Pulmo ves (+/+), rh (-/-), wh (-/-) partum
History DM in family (-), HT (-), Cor : S1S2 single regular, Nifedipine tab 10
asthma (-), allergic (-) murmur (-), gallop(-) mg/ 8 hour
Abdomen: DC
LMP: 5-11-2016 Scar (-), striae gravidarum (-),
EDD: 12-08-2017 linea nigra (+)
GW : 35-36 weeks Extremity: oedema (+/+), warm
(+/+) SPV advice :
History of ANC: Treat severe pre
History of USG: Obs status: eclampsia based
History of family planning: - L1 : breech on NTB GH
Next family planning : injection 3 L2 : back on the right side guideline
month L3 : head
L4: 5/5

UFH: 31 cm
EFW : 2945 gr
FHB : 12-12-12 (144x bpm)
UC : -
VT : -
Patella Reflex +
TIME SUBJECTIVE OBJECTIVE ASSESSMENT PLANNING

Obstetrical history: Laboratory exam (7/7/2017):

1. This HGB: 8,2
RBC: 4,06
HCT: 26,9
MCV: 66,3
MCH: 20,3
MCHC: 30,6
WBC: 9,51
PLT: 268

Hbs Ag non reactive

PPT 13,4
APTT 33,7
Proteinuria +1