FETOMATERNAL WARD

REPORT
Thursday, June 2nd 2016

Supervisors : 1. dr.

Residents :

1. dr. Rizky Fachriza Harahap

2. dr. Paul Alwin Khoman
3. dr. Dedet Steavano

Department of Obstetrics and Gynecology

Medical Faculty Universitas Sumatera Utara
Adam Malik General Hospital
2016

Ward Patient
patient

1. Mrs. F, 22 yo, P1A0

Diagnosis : Post CS d/t Eclampsia + Partial HELLP syndrome + NH5
Plan

: Continue Therapy

Supervisor: dr. Letta S Lintang, Mked(OG), SpOG

Follow up Monday, 4th of January 2015 08.00 am

Chief Complaint: Blurry Vision
Present state
Level of Cons

: Alert

Anemic : (-)/(-)

BP

: 180/100 mmHg

Icteric

: (-)/(-)

HR

: 84 times/minute

Cyanosis

RR

: 20 times/minute

Dyspnea: (-)

Temperature

: 37 0C

: (-)

Oedem : (-)

Generalized state
Head

: Eye

: Conjuctive Palpebra Inferior anemic -/-,

icteric -/Nose
Ear

: Within normal limit

: Within normal limit

Mouth : Within normal limit

Neck

: JVP R-2 cmH2O, enlargement of lymph node(-)

Thorax
:
Breathing sound : Vesicular, rales (-)
Heart
: Cor S1S2 (N)
Obstetric State :
Abdomen
: Laxed, Peristaltic (+) N
Fundal Height : 2 fingers below the navel
Vaginal bleeding
: (-), lochia (+) rubra
Operation wound
: Covered by sterile gauge, dry
Urination
: (+) via catheter, UOP 50 cc/hour, clear
Defecation
: (-), flatus (+)

Dx

: Post CS d/t Eclampsia + Partial HELLP Syndrome + NH2

Th/
-IVFD RL 20 drops /minute
-Inj Meropenem 1 gr/12 hour
-Inj Perdipine 10,5 cc/hour
-Inj Dexamethasone 10-10-5-5
-Captopril tablet 3x25mg
Plan:
-Consult ophthalmology department

Ophtalmology Department Consult

Dx: Left eye retinal detachment
Th/
-Cendo lyters 4 drops on the left eye
Plan:
-Control to ophthalmology polyclinic

Follow up Tuesday, 5th of January 2015 08.00 am

Chief Complaint: Blurry Vision
Present state
Level of Cons

: Alert

Anemic : (-)/(-)

BP

: 150/100 mmHg

Icteric

: (-)/(-)

HR

: 81 times/minute

Cyanosis

RR

: 18 times/minute

Dyspnea: (-)

Temperature

: 36,7 0C

: (-)

Oedem : (-)

Generalized state
Head

: Eye

: Conjuctive Palpebra Inferior anemic -/-,

icteric -/Nose
Ear

: Within normal limit

: Within normal limit

Mouth : Within normal limit

Neck

: JVP R-2 cmH2O, enlargement of lymph node(-)

Thorax
:
Breathing sound : Vesicular, rales (-)
Heart
: Cor S1S2 (N)
Obstetric State :
Abdomen
: Laxed, Peristaltic (+) N
Fundal Height : 2 fingers below the navel
Vaginal bleeding
: (-), lochia (+) rubra
Operation wound
: Covered by sterile gauge, dry
Urination
: (+) via catheter, UOP 60 cc/hour, clear
Defecation
: (-), flatus (+)

Dx

: Post CS d/t Eclampsia + Partial HELLP Syndrome + NH3

Th/
-IVFD RL 20 drops /minute
-Inj Meropenem 1 gr/12 hour
-Inj Perdipine 10,5 cc/hour
-Captopril tablet 3x25mg
Plan:
-Discharge from ICU (Passbed)

Follow up Wednesday, 6th of January 2015 08.00 am

Chief Complaint: Blurry Vision
Present state
Level of Cons

: Alert

Anemic : (-)/(-)

BP

: 135/100 mmHg

Icteric

: (-)/(-)

HR

: 86 times/minute

Cyanosis

RR

: 20 times/minute

Dyspnea: (-)

Temperature

: 36,6 0C

: (-)

Oedem : (-)

Generalized state
Head

: Eye

: Conjuctive Palpebra Inferior anemic -/-,

icteric -/Nose
Ear

: Within normal limit

: Within normal limit

Mouth : Within normal limit

Neck

: JVP R-2 cmH2O, enlargement of lymph node(-)

Thorax
:
Breathing sound : Vesicular, rales (-)
Heart
: Cor S1S2 (N)
Obstetric State :
Abdomen
: Laxed, Peristaltic (+) N
Fundal Height : 2 fingers below the navel
Vaginal bleeding
: (-), lochia (+) rubra
Operation wound
: Covered by sterile gauge, dry
Urination
: (+) via catheter, UOP 70 cc/hour, clear
Defecation
: (-), flatus (+)

Dx

: Post CS d/t Eclampsia + Partial HELLP Syndrome + NH4

Th/
-IVFD RL 20 drops /minute
-Inj Meropenem 1 gr/12 hour
-Nifedipine 3x10 mg
Plan:
-Catheter removal
-Wound toilet
-Check Routine blood, HELLP Panel

Follow up Thursday, 7th of January 2015 08.00 am

Chief Complaint: Blurry Vision
Present state
Level of Cons

: Alert

Anemic : (-)/(-)

BP

: 135/95 mmHg

Icteric

: (-)/(-)

HR

: 81 times/minute

Cyanosis

RR

: 20 times/minute

Dyspnea: (-)

Temperature

: 37 0C

: (-)

Oedem : (-)

Generalized state
Head

: Eye

: Conjuctive Palpebra Inferior anemic -/-,

icteric -/Nose
Ear

: Within normal limit

: Within normal limit

Mouth : Within normal limit

Neck

: JVP R-2 cmH2O, enlargement of lymph node(-)

Thorax
:
Breathing sound : Vesicular, rales (-)
Heart
: Cor S1S2 (N)
Obstetric State :
Abdomen
: Laxed, Peristaltic (+) N
Fundal Height : 2 fingers below the navel
Vaginal bleeding
: (-), lochia (+) rubra
Operation wound
: Covered by sterile gauge, dry
Urination
: (+)
Defecation
: (-), flatus (+)

Dx

: Post CS d/t Eclampsia + Partial HELLP Syndrome + NH5

Th/
-IVFD RL 20 drops /minute
-Inj Meropenem 1 gr/12 hour
-Nifedipine 3x10 mg
Plan:
-Continue therapy

02/01/16

04/01/16

06/01/16

Hb
Ht
Leu
PLT

Hb : 9,3 gr/dL
Ht : 28,1
Leu : 25000 /mm3
PLT : 139000
/mm3

Hb
Ht
Leu
PLT

: 10,2 gr/dL
: 30,5
: 18000 /mm3
: 61000/mm3

PT
: 12,8 (C 14 s)
APTT: 26,19 (C 33,5 s)
TT
: 20,5 (C 17,5 s)
INR : 0,9
Fibrinogen: 332
D-Dimer: 1900
Albumin: 2,6
Random blood glucose: 95
mg/dL
Ureum
: 79 mg/dL
Creatinine: 1,62 mg/dL
Na
K
Cl
Proteinuria

: 134 mEq/L
: 4,5 mEq/L
: 106 mEq/L
Urinalysis : +2

: 9,2 gr/dL
: 28,6
: 24280 /mm3
: 245000/mm3

Fibrinogen: 185
D-Dimer: 235
SGOT/SGPT: 56/56
LDH: 834
Ureum
: 35.8
mg/dL
Creatinine: 0.75
mg/dL

THANK YOU