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    Case 3

    Name : Mrs. A

    Age : 18 years old

    Address : Lingsar

    Admitted : October 1st, 2015

    RM : 121!2

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    Time Subject Object Assessment Plan

    01"10"20151.50

    #atient re$erred $rom %igerongan#&' (it) *1#0A0L0 + (s%-L-/ )ead resentation,mot)er and $ets (ell beingss. #ROM. #atient came toN3 *&, con$essed (aterleaed ot $rom )er (omb since0"0+"2015 42.00 A6,bloody slim 4"6, abominal ain 4"6,7M 46.

    No )istory o$ 9M, &, ast)ma.

    LM# : 01-01-201;99 : 08-10-2015

    &istory AN' : 12< at #osyandand N3 *&Last AN' : 01-10-2015Reslt: 3# : 120-+0, 3 =5g,* !"8 (ees, /7& 1 cm,)ead resentation, 7&346152

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    Time Subjective Objective Assessment Plann

    15.00 Abdominal ain 4"6

    *'%: 'M 4;>5M=63# : 120-80 mm&g&R: 88 5M=63# : 120-80 mm&g&R: 88

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    2.00 Abdominal ain 4"6 *'%: 'M 4;>5M=63# : 120-80 mm&g&R: +=

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    Time Subjective Objective Assessment

    Planning

    10.00 *': (ell 'ons: 'M3#: 120-!0 &R: +0 bmRR: 20tm : !,1o'/': (ell, /O : 100 cc-)ors/7&: on mbilics, Loc)ea rbra:

    Acti@e 3leeding 4"6, Oeration (ondnormal

    3aby in N'/:&3 : 1= bmRR : = tm: =,8D'

    2 )ors ostc"section

    Obser@ed mot)er and babeing

    %ggest mot)er to eat amot)er didnEt $eel nase@omiting

    %ggest mot)er to do eamobilisation.

    " nB Amicillin 1gr-= )ors

    0-10-20150!.00

    #atient con$essed(ond ain

    *': (ell 'ons: 'M3#: 110-!0 &R: 8 bmRR: 22 tm : =,5o'/': , /O : 150 cc-)ors/7&: 2 $ingers belo( mbilicsLoc)ea rbra: Oeration (ond (ell cared

    3aby in N'/:

    &3 : 1 bmRR : 8 tm: =,!D'

    One dayost c"section

    Obser@ed mot)er and b %ggest mot)er to mobi

    and drin, medication. 'ontine t)eray

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