Case 2

• Name : Mrs. A
• Age : 36 years old
• Address : Lingsar, Narmada
• Admitted : APRIL 25th 2017
 c Subject Object Assessment Planning
25/04/17 Patient with P5A0H4 post partum General status P5A0 H4 Post • Obs. Vital sign
15:48 7 days with GC : weak partum 7 days with • Pro usg
WITA Eclampsia. Patient confessed GCS: E4V5M6 preeklampsia + sub • DM co GP
dizziness (+), headache (+) ,blur BP : 170/100 mmHg involusio Advice :
vision (+) and edema foot (+). PR: 88 ppm - Asam mefenamat
History of convulsions (-). RR: 20 rpm 500 mg
History of DM (-), HT (-), asthma T: 36,7 °C -Nifedipin oral 10 mg/ 8
(-). Convulsions before hours
pregnancy (-). Local status - communication
Eye : an (-/-), ict (-/-) information and
History of ANC: 8x at Posyandu Pulmo: ves (+/+), rh (-/-), wh (- educated
Last ANC: 16/4/2017  Twins /-)
History of USG: 1x at Sp.OG Cor : S1S2 single regular M(-),
Last: 18/04/17 G(-)
Result  Twins, 1577/1519 gram Abd : distention (-)
Ext : edema (+/+), warm acral
History of family planning: (+/+)
Injection 3 months
Next family planning: : IUD UFH: ½ pusat sympisis
Active bleeding: (+)
Obstetric History:
I. Male/ Aterm/house/
normal/death
II. Male/aterm/normal/house/de
ath
Time Subject Object Assessment Planning
20:00 S/ headache (+) - BP : 130/80 mmHg P5A0 H4 Post Obs.vital sign
- PR : 86 tpm partum 7 Move to VK
- RR : 20 tpm days with teratai
- T : 36,6oC preeklampsia
Active bleeding: (-) + sub
involusio