patient report

8/16/2019 Patient Report

1/29

New patient : - patient

Prior patient : 1 patient


2/29

1. Mrs. N, 29 yo, G3P1A1

Dx: PEB+ KJDK+ MG+ KDR(28-30)w!+ "#!$

Pr#s#%&!&'o%

P!% : - *o%&!%#os !'%! D#'#ry


3/29

Present state:

• Sens : Alert Anemis (-)

• BP : 180/ 120 mmHg Icteric (-)

• H : !0 "/I Sianosis (-)

• : 2# "/I $%spnoe (-)

• & : ' *+ema (-)

Localized St :Hea+ : on, Palpera in.erior anemis ( -)/(-) icteric (-

Nec: in normal limit

&ora" : espirator% son+ : 3esicler

A++itional son+ : 4ee5ing(-)/(-) oni (-)/(-)

*"tremit% : pretiial e+ema (6) 7P/AP : (6)/(6) N

ollow 9p at 8 A


4/29

Obstetrical State

• A+omen : S%metricall% enlarge+

• n+al eigt : ' ;ngers ao


5/29

Dx : PEB+ KJDK+ MG+ KDR(28-30)w!+ "#!$ Pr#s#%&!&'o%

Therapy:- Indwelling Catheter - IVFD RL + MgSO4 40 ! "0 ##$ %& gr' %4 drip()*inte( !*aintenan#e

-IVFD RL+ ,xit,xin -I. 4drip()*inte titrate 4 drip()*inte e/ery %- *i40drip() *inte

- 1i2edipine %0 *g e/ery "0 *inte( i2 3 5 %60)%%0 **7g$ with *axi**

h,r($ and with *aintenan#e 4 x %0 *g

lanning : C8Se#ti,n

Rep,rt t, Sp/ Dr Mel/in 19 3ar($ Med!O9'$ SpO9

;CC


6/29

Present state:


• BP : 1C0/ 100 mmHg Icteric (-)

• H : !0 "/I Sianosis (-)

• : 20 "/I $%spnoe (-)

• & : ' *+ema (-)






ollow 9p at # P


7/29

Obstetrical State




8/29



-IVFD RL+ ,xit,xin %0I. 4drip()*inte titrate 4 drip()*inte e/ery %- *40drip() *inte



lanning : C8Se#ti,n

Rep,rt t, Sp/ Dr Mel/in 19 3ar($ Med!O9'$ SpO9

;CC


9/29

Present state:



• H : 88 "/I Sianosis (-)

• : 2# "/I $%spnoe (-)

• & : ' *+ema (-)






ollow 9p at 8 P

Ob i l S


10/29

Obstetrical State




11/29



-IVFD RL+ ,xit,xin %0I.

4drip()*inte titrate 4 drip()*inte e/ery %- *40drip() *inte



lanning : Sp,ntane,( Vaginal Deli/ery

Rep,rt t, Sp/ Dr Mel/in 19 3ar($ Med!O9'$ SpO9 ;CC


12/29

Present state:



• H : 88 "/I Sianosis (-)

• : 20 "/I $%spnoe (-)

• & : ' *+ema (-)

Localized St :

Hea+ : on, Palpera in.erior anemis ( -)/(-) icteric (-





ollow 9p at 10 P

Ob t t i l St t


13/29

Obstetrical State




14/29


Therapy:- Indwelling Catheter - IVFD RL + MgSO4 40 ! "0 ##$ %& gr' %4 drip()*inte !*aintenan#e

-IVFD RL &0 dr,p() *inte




Rep,rt t, Sp/ Dr dr M Fidel 9ani( Siregar Med!O9'$ SpO9 ;CC


15/29

Obstetrical State


16/29

Obstetrical State




17/29


Therapy:- Indwelling Catheter - IVFD RL + MgSO4 40 ! "0 ##$ %& gr' %4 drip()*inte !*aintenan#e -

IVFD RL &0 dr,p() *inte- 1i2edipine %0 *g e/ery "0 *inte( i2 3 5 %60)%%0 **7g$ with *axi**




18/29

&HAN7 G9

O’cloc Sens Bp HR RR Temp UOP Nifedipi


19/29

k p p p

ne

08F00 180/120

!0 2# 'C C0 10 mg

08F1C 1@0/110

88 20 'C C0

08F'0 1C0/100

88 20 ' C0

08F#C 1C0/100

8@ 20 ' C0

0!F00 1C0/120

!0 20 'C C0

0!F1C 1@0/110

88 20 'C C0

0!F'0 1C0/100

88 20 ' C0

0!F#C 1C0/100

8@ 20 ' C0

10F00 180/120

!0 20 'C C0 10 mg

10F1C 1@0/110

88 20 'C C0



20/29

k p p p

ne

11F00 1C0/120

!0 20 'C C0

11F1C 1@0/110

88 20 'C C0

11F'0 1C0/100

100 20 ' C0

11F#C 1C0/100

!0 20 ' C0

12F00 1C0/120

!0 2# 'C C0

12F1C 1@0/110

88 20 'C C0

12F'0 1C0/100

100 20 ' C0

12F#C 1C0/100

!0 20 ' C0

1'F00 180/120

!0 20 'C C0 10 mg

1'F1C 180/110

88 20 'C C0



21/29

k ne

1#F00 1C0/120

!0 20 'C C0

1#F1C 1@0/110

88 20 'C C0

1#F'0 1C0/100

100 20 ' C0

1#F#C 1C0/100

!0 20 ' C0

1CF00 1C0/120

!0 20 'C C0

1CF1C 1@0/110

88 20 'C C0

1CF'0 1C0/100

100 20 ' C0

1CF#C 1C0/100

!0 20 ' C0

1@F00 1C0/120

!0 20 'C C0

1@F1C 1C0/110 88 20 'C C0



22/29

k ne

1F00 1C0/120

!0 20 'C C0

1F1C 1@0/110

88 20 'C C0

1F'0 1C0/10

0

100 20 ' C0

1F#C 1C0/100

!0 20 ' C0

18F00 1C0/120

!0 20 'C C0

18F1C 1@0/110

88 20 'C C0

18F'0 1C0/100

100 20 ' C0

18F#C 1C0/100

!0 20 ' C0

1!F00 1C0/120

!0 20 'C C0 10mg

1!F1C 1C0/110 88 20 'C C0

O’clock

Sens Bp HR RR Temp UOP Nifedipi


23/29

k ne

20F00 1C0/120

!0 20 'C C0

20F1C 1@0/110

88 20 'C C0

20F'0 1C0/10

0

100 20 ' C0

20F#C 1C0/100

!0 20 ' C0

21F00 1C0/120

!0 20 'C C0

21F1C 1@0/110

88 20 'C C0

21F'0 1C0/100

100 20 ' C0

21F#C 1C0/100

!0 20 ' C0

22F00 1C0/120

!0 20 'C C0

22F1C 1C0/110 88 20 'C C0

O’clock

Sens Bp HR RR Temp UOP Nifedipi


24/29

k ne

2'F00 1C0/120

!0 20 'C C0 10mg

2'F1C 1@0/110

88 20 'C C0

2'F'0 1C0/10

0

100 20 ' C0

2'F#C 1C0/100

!0 20 ' C0

00F00 1C0/120

!0 20 'C C0

01F1C 1@0/110

88 20 'C C0

01F'0 1C0/100

100 20 ' C0

01F#C 1C0/100

!0 20 ' C0

02F00 1C0/120

!0 20 'C C0

02F1C 1C0/110 88 20 'C C0

O’clock

Sens Bp HR RR Temp UOP Nifedipine


25/29

k ne

0'F00 1C0/120

!0 20 'C C0

0'F1C 1@0/110

88 20 'C C0

0'F'0 1C0/10

0

100 20 ' C0

0'F#C 1C0/100

!0 20 ' C0

0#F00 1C0/120

!0 20 'C C0

0#F1C 1@0/110

88 20 'C C0

0#F'0 1C0/100

100 20 ' C0

0#F#C 1C0/100

!0 20 ' C0

0CF00 1C0/120

!0 20 'C C0 10mg

0@F1C 1C0/110 88 20 'C C0

O’clock

Sens Bp HR RR Temp UOP Nifedipine


26/29

k ne

0F00 1C0/120

!0 20 'C C0

0F1C 1@0/110

88 20 'C C0

0F'0 1C0/10

0

100 20 ' C0

0F#C 1C0/100

!0 20 ' C0

08F00 1C0/120

!0 20 'C C0


27/29


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patient report

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