Mrs.

Eka Susanti 32 yo RM 00858035

P5A0H4 post SC day 2 th indication transverse lie +suspect ileus obstructive
20 December 2018
S Objektif Assesment Plan
Dyspneu (+), General state: GCS 10 P5A0H4 post SC • Observation general
stomatch feel
distended (+)
BP: 114/80 mmHg, HR: 132x/m, RR 42x/m, T: day 2 th indication state, TTV
38,70C transverse lie • IVFD RL 20 tpm
+ileus paralitic + • Inj omeprazole 21
acidosis metabolic • Ceftriaxone 2x1 gr IV
• Inj metronidazole
3x500 mg
• Inj furosemid 1 amp
Laboratorium (22/12/2018): • Inj ketorolac 3x 30mg
pH: 7,32 / PO2: 85 / Be: 10 / PCO2: 29 / HCO3: • Inhalasi
15acidosis metabolic ventolin:bisolvon:
Follow up 23 NaCl=1:1:1:1
December 2018 at
7 am
Electrolit • Dulcolac sup 2x1/
Na: 139 / Laktat: 5,7 / proteinuria: +1 rectal
• Ambroxol 3x1 tab
• Furmain1x1
• Inf Paracetamol 3x1
• Instruction by
internist (dr marlina
Sp.PD)
• Instruction to
Visited by dr. Sinta Sp. B pulmonology
 Mrs. Eka Susanti 32 yo RM 00858035
P5A0H4 post SC day 2 th indication transverse lie +suspect ileus obstructive
20 December 2018
l Objektif Assesment Plan

visited by dr. Shinta Sp. B • Instruction to

pulmonology
• Instruction to
cardiology
• Fasting
• Two potition
abdominal radiograph
• Dulcolac 2x1
• Nebulizer on going

instruction by internist (dr. Marlina Sp.PD) • Meylon 2 fls/ 50 meq

in 500 ml NaCl 0,9%
/12 jam
• Inj. Lasix 1x1 amp
General state: GCS: 6
23-12-20018
BP: 86/52 mmHg, HR: 138x/m, RR 41/m, T: • Therapy on going
14.00 WIB
38,50C

23-12-20018 General state: GCS 3 • Patient upnea

18.00 WIB BP: 53/32 mmHg. HR: - RR: - T:-
 Mrs. Febrina 28 yo RM 011003961
P1A0H1 not in labor+ super imposed pre eclampsia +impending eclamsia+ singleton live head
presentation+ acute lung oedema
l Objektif Assesment Plan
Shortness of General state: GCS P1A0H1 post SC • Observation general
breath (-)
BP 124/80 mmHg, HR: 82x/m, RR 18x/m, T: indication state
36,70C PEB+acute lung • IVFD RL drip 20
oedema+hypoalbu tpm/menit
min • Ceftriaxon 2x1 gr
Abdoment: hundal height 2 finger below POD III • Inj. Lasix 3x1 amp
umbilicus, ood contraction • Ranitidin 2x1 amp
• Ketorolac 3x1 amp
Genitalia externa: lochia (+) rubra • Dexametason 3x1
amp
Follow up tgl 24 • Metildopa 3x500 mg
Desember 2018 Laboratorium (22/12/2018) • Nebulizer
Hb: 7,6 / Leokosit: 17.830/ trombosit: 250.000/ ventolin+pulmicort
Hematokrit: 23,5% 3x1
• Transfution PRC 4
labu