S Objektif Assesment Plan: Dyspneu (+), Stomatch Feel Distended (+)

Mrs. Eka Susanti 32 yo RM 00858035 P5A0H4 post SC day 2 th indication transverse lie +suspect ileus obstructive 20 December 2018 S

Objektif

Dyspneu (+), stomatch feel distended (+)

General state: GCS 10 P5A0H4 post SC BP: 114/80 mmHg, HR: 132x/m, RR 42x/m, T: day 2 th indication 38,70C transverse lie +ileus paralitic + acidosis metabolic

Laboratorium (22/12/2018): pH: 7,32 / PO2: 85 / Be: 10 / PCO2: 29 / HCO3: 15acidosis metabolic Follow up 23 December 2018 at 7 am

Electrolit Na: 139 / Laktat: 5,7 / proteinuria: +1

Assesment

Plan

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Visited by dr. Sinta Sp. B

Observation general state, TTV IVFD RL 20 tpm Inj omeprazole 21 Ceftriaxone 2x1 gr IV Inj metronidazole 3x500 mg Inj furosemid 1 amp Inj ketorolac 3x 30mg Inhalasi ventolin:bisolvon: NaCl=1:1:1:1 Dulcolac sup 2x1/ rectal Ambroxol 3x1 tab Furmain1x1 Inf Paracetamol 3x1 Instruction by internist (dr marlina Sp.PD) Instruction to 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

visited by dr. Shinta Sp. B

Assesment

Plan

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instruction by internist (dr. Marlina Sp.PD)

23-12-20018 14.00 WIB

General state: GCS: 6 BP: 86/52 mmHg, HR: 138x/m, RR 41/m, T: 38,50C

23-12-20018 18.00 WIB

General state: GCS 3 BP: 53/32 mmHg. HR: - RR: - T:-

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

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Meylon 2 fls/ 50 meq in 500 ml NaCl 0,9% /12 jam Inj. Lasix 1x1 amp

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Therapy on going

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Patient upnea

Mrs. Febrina 28 yo RM 011003961 P1A0H1 not in labor+ super imposed pre eclampsia +impending eclamsia+ singleton live head presentation+ acute lung oedema l

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Shortness of breath (-)

General state: GCS P1A0H1 post SC BP 124/80 mmHg, HR: 82x/m, RR 18x/m, T: indication 36,70C PEB+acute lung oedema+hypoalbu min Abdoment: hundal height 2 finger below POD III umbilicus, ood contraction Genitalia externa: lochia (+) rubra

Follow up tgl 24 Desember 2018

Laboratorium (22/12/2018) Hb: 7,6 / Leokosit: 17.830/ trombosit: 250.000/ Hematokrit: 23,5%

Assesment

Plan

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Observation general state IVFD RL drip 20 tpm/menit Ceftriaxon 2x1 gr Inj. Lasix 3x1 amp Ranitidin 2x1 amp Ketorolac 3x1 amp Dexametason 3x1 amp Metildopa 3x500 mg Nebulizer ventolin+pulmicort 3x1 Transfution PRC 4 labu