Ward Report

Monday, 1st February 2016

Supervisor:
dr. Marwan Indramirsyah, M.Ked(OG), Sp.OG
dr. Muara P Lubis, M.Ked(OG), Sp.OG

Residents:
dr. Rizky Fachriza Hrp
dr. Paul A Khoman

Department of Obstetric and Gynecology

Medical Faculty of Universitas Sumatera Utara
Adam Malik General Hospital
2016

Ward Patient: 1 Patient

1. Mrs. S, 35 yo, P4A1

Diagnosis : Post CS d/t Severe preeclampsia + Partial HELLP
syndrome + Post Poomeroy sterilization + PD 6 +
Thrombocytopenia + AKI std risk

Supervisor in charge : dr. Muara P Lubis, M.Ked(OG), Sp.OG

Plan
:
. 1
.

PATIENT 1

FOLLOW UP
Wednesday, 27th January 2016
Chief Complaint: Pain on the abdominal wound
Present State
Consc

: Alert

Anemic

: (-)

Icteric

: (-)
: (-)

BP

: 140/85 mmHg

HR

: 89 x/i

Cyanotic

RR

: 19 x/i

Dispnoe

Temp : 36,8oC

Oedem

: (-)
: (-)

Generalized state
Head

Eye
Nose

: Conj palp inf anemic (-/-), icteric sclera (+/+)

: Epistaxis (-)

Mouth : Gingival bleeding (-)

Thorax

: Respiratory sound: Vesicular, Additional sound: (-)

Abdomen
Extremities

: Liver & Spleen not palpable

: Superior Inferior purpura (-)

Localised state
Abdomen

: Laxed, peristaltic (+) weak

Fundal Height

: 2 fingers below navel, strong contraction

Operative Wound

: Covered by sterile gauge, impression: dry

Vaginal Bleeding

: (-), lochia (+) rubra

Micturition

: (+) via catheter, UOP = 50 cc / hour, dark yellow

Defecation

: (-), flatus (-)

Diagnosis : Post CS d/t Severe preeclampsia + Partial HELLP syndrome +

Post Poomeroy sterilization + PD 1 + Thrombocytopenia + AKI
std risk
Therapy :

IVFD RL + MgSO4 40% (30cc) 14 drops/minute

IVFD RL + Oxytocin 10-10-5-5 IU 20 drops/minute

Inj Ceftriaxone 1 gr/12 hour

Metronidazole drips 500 mg/8 hour

Inj Dexamethasone rescue 10 mg-10 mg-5 mg-5 mg / 12 hour

Inj Ketorolac 30 mg/8 hour

Inj Alinamin-F 1 amp/8 hour

Amlodipine 1x10 mg

Nifedipine 1 x 10 mg

Plan :

Continue therapy

Consult HOM, Nephrology, & Gastroenterohepatology department

Perform routine blood count, HELLP panel, LFT, RFT, Fibrinogen, D-

HOM Division Consult Answer

Diagnosis : Thrombocytopenia + Post CS d/t Severe preeclampsia + Partial
HELLP Syndrome + PD 1 + AKI std risk
Therapy
:

According to OBGYN department

Plan

:
Perform routine blood count, HELLP panel, LFT, RFT, Bilirubin total,
Bilirubin direct, Fibrinogen, D-Dimer, ALP, LDH, Albumin

Nephrology Division Consult Answer

Diagnosis

: AKI std risk + Post CS d/t Severe preeclampsia + Partial HELLP

Syndrome + PD 1 + Thrombocytopenia

Therapy
:

According to OBGYN department

Plan

:
Perform RFT
Perform kidney and urinary tract ultrasonography when patients
condition is stable

Gastroenterohepatology
Answer
Diagnosis

(GEH)

Division

Consult

: Cholestasis intra hepatic + Post CS d/t Severe preeclampsia +

Partial HELLP
DD extra hepatic
syndrome + PD 1 + Thrombocytopenia

Therapy
:

According to OBGYN department

Plan

:
Perform LFT
Perform abdominal ultrasonography when patients condition is
stable

26/01/16
(06:54)
Hb
Ht
Leu
PLT

26/01/16
(15:00)

: 14,2 gr/dL
: 38,5 %
: 7690 /mm3
: 31.000 /mm3

PT
: 12,5 (C 13,9 s)
APTT: 33,2 (C 33,9 s)
TT
: 22,3 (C 17,5 s)
INR : 0,93
Fibrinogen: 299 mg/dL
D-Dimer : 2200 ng/mL
Ureum
: 67,47
mg/dL
Creatinine: 1,96 mg/dL
Albumin
Na
K
Cl
mEq/L

: 3,0 g/dL
: 135 mEq/L
: 3,5 mEq/L
: 102

LDH: 1936 U/L

HBsAg : Negative
Anti HCV: Negative
Urynalisis: Protein
+3

Hb
Ht
Leu
PLT

: 11,9 gr/dL
: 32,2
: 13.710 /mm3
: 55.000 /mm3

27/01/16
Hb
Ht
Leu
PLT

: 8,4 gr/dL
: 22,8 %
: 23.610 /mm3
: 101.000 /mm3

Fibrinogen: 401 mg/dL

D-Dimer : 572 ng/mL
Bilirubin total : 4,42
Bilirubin direct: 4,1
ALP: 104
SGOT/SGPT : 142/143
GT
: 34
Protein total: 5,5
Albumin
: 2,9 g/dL
Globulin
: 2,6

FOLLOW UP
Thursday, 28th January 2016
Chief Complaint: Pain on the abdominal wound
Present State
Consc

: Alert

Anemic

: (-)

Icteric

: (-)
: (-)

BP

: 140/90 mmHg

HR

: 85 x/i

Cyanotic

RR

: 17 x/i

Dispnoe

Temp : 36,5oC

Oedem

: (-)
: (-)

Generalized state
Head

Eye
Nose

: Conj palp inf anemic (-/-), icteric sclera (+/+)

: Epistaxis (-)

Mouth : Gingival bleeding (-)

Thorax

: Respiratory sound: Vesicular, Additional sound: (-)

Abdomen
Extremities

: Liver & Spleen not palpable

: Superior Inferior purpura (-)

Localised state
Abdomen

: Laxed, peristaltic (+)

Fundal Height

: 2 fingers below navel, strong contraction

Operative Wound

: Covered by sterile gauge, impression: dry

Vaginal Bleeding

: (-), lochia (+) rubra

Micturition

: (+) via catheter, UOP = 70 cc / hour, yellow

Defecation

: (-), flatus (+)

Diagnosis

: Post CS d/t Severe preeclampsia + Partial HELLP syndrome +

Post Poomeroy sterilization + PD 2 + Thrombocytopenia + AKI
std risk

Therapy
:

IVFD RL 20 drops/minute

Inj Ceftriaxone 1 gr/12 hour

Metronidazole drips 500 mg/8 hour

Inj Ketorolac 30 mg/8 hour

Amlodipine 1x10 mg

Plan
:

Continue therapy

Liver & Abdomen

Gastroenterohepatology division)

ultrasonography

(Nephrology

&

FOLLOW UP
Friday, 29th January 2016
Chief Complaint: Pain on the abdominal wound
Present State
Consc

: Alert

Anemic

: (+)

Icteric

: (+)

BP

: 150/90 mmHg

HR

: 90 x/i

Cyanotic

RR

: 18 x/i

Dispnoe

Temp : 36,6oC

Oedem

: (-)
: (-)
: (-)

Generalized state
Head

Eye
Nose

: Conj palp inf anemic (-/-), icteric sclera (+/+)

: Epistaxis (-)

Mouth : Gingival bleeding (-)

Thorax

: Respiratory sound: Vesicular, Additional sound: (-)

Abdomen
Extremities

: Liver & Spleen not palpable

: Superior Inferior purpura (-)

Localised state
Abdomen

: Laxed, peristaltic (+)

Fundal Height

: 2 fingers below navel, strong contraction

Operative Wound

: Covered by sterile gauge, impression: dry

Vaginal Bleeding

: (-), lochia (+) rubra

Micturition

: (+) via catheter, UOP = 70 cc / hour, yellow

Defecation

: (-), flatus (+)

Diagnosis

: Post CS d/t Severe preeclampsia + Partial HELLP syndrome +

Post Poomeroy sterilization + PD 3 + Thrombocytopenia + AKI
std risk

Therapy
:

IVFD RL 20 drops/minute

Inj Ceftriaxone 1 gr/12 hour

Metronidazole drips 500 mg/8 hour

Inj Ketorolac 30 mg/8 hour

Amlodipine 1x10 mg

Plan

:
Liver
&
Abdomen
ultrasonography
(Nephrology
&
Gastroenterohepatology division)
Complete blood count, HST, BT, RFT, LFT, D-Dimer, Fibrinogen, LDH

FOLLOW UP
Saturday, 30th January 2016
Chief Complaint: Pain on the abdominal wound
Present State
Consc

: Alert

Anemic

: (+)

Icteric

: (+)

BP

: 145/90 mmHg

HR

: 82 x/i

Cyanotic

RR

: 20 x/i

Dispnoe

Temp : 36,5oC

Oedem

: (-)
: (-)
: (-)

Generalized state
Head

Eye
Nose

: Conj palp inf anemic (-/-), icteric sclera (+/+)

: Epistaxis (-)

Mouth : Gingival bleeding (-)

Thorax

: Respiratory sound: Vesicular, Additional sound: (-)

Abdomen
Extremities

: Liver & Spleen not palpable

: Superior Inferior purpura (-)

Localised state
Abdomen

: Laxed, peristaltic (+)

Fundal Height

: 2 fingers below navel, strong contraction

Operative Wound

: Covered by sterile gauge, impression: dry

Vaginal Bleeding

: (-), lochia (+) rubra

Micturition

: (+) via catheter, UOP = 60 cc / hour, clear

Defecation

: (-), flatus (+)

Diagnosis

: Post CS d/t Severe preeclampsia + Partial HELLP syndrome +

Post Poomeroy sterilization + PD 4 + Thrombocytopenia + AKI
std risk

Therapy
:

IVFD RL 20 drops/minute

Inj Ceftriaxone 1 gr/12 hour

Metronidazole drips 500 mg/8 hour

Inj Ketorolac 30 mg/8 hour

Amlodipine 1x10 mg

Plan

:
Continue therapy
PRC Transfussion: (10-6,6) x 50 x 3 / 175cc = 2,91 3 PRC
Consult internal division for transfusion tolerance

27/01/16

29/01/16

Hb
Ht
Leu
PLT

Hb : 6,6 gr/dL
Ht : 22,8 %
Leu : 15.540 /mm3
PLT : 139.000
/mm3

: 8,4 gr/dL
: 22,8 %
: 23.610 /mm3
: 101.000 /mm3

Fibrinogen: 401 mg/dL

D-Dimer : 572 ng/mL
Bilirubin total : 4,42
Bilirubin direct: 4,1
ALP: 104
SGOT/SGPT : 142/143
GT
: 34
Protein total: 5,5
Albumin
: 2,9 g/dL
Globulin
: 2,6

BT: 3
PT
: 10 (C:
14,3)
APTT: 24
(C:
34,5)
TT
: 25,6 (C:
17,5)
SGOT/SGPT :
62/53
LDH
:
1002
BUN
Ureum
Creatinine

: 78
: 167
: 3,3

26/01/16
(06:54)
Hb
Ht
Leu
PLT

26/01/16
(15:00)

: 14,2 gr/dL
: 38,5 %
: 7690 /mm3
: 31.000 /mm3

PT
: 12,5 (C 13,9 s)
APTT: 33,2 (C 33,9 s)
TT
: 22,3 (C 17,5 s)
INR : 0,93
Fibrinogen: 299 mg/dL
D-Dimer : 2200 ng/mL
Ureum
: 67,47
mg/dL
Creatinine: 1,96 mg/dL
Albumin
Na
K
Cl
mEq/L

: 3,0 g/dL
: 135 mEq/L
: 3,5 mEq/L
: 102

LDH: 1936 U/L

HBsAg : Negative
Anti HCV: Negative
Urynalisis: Protein
+3

Hb
Ht
Leu
PLT

: 11,9 gr/dL
: 32,2
: 13.710 /mm3
: 55.000 /mm3

FOLLOW UP
Sunday, 31st January 2016
Chief Complaint:
Present State
Consc

: Alert

Anemic

: (+)

Icteric

: (+)

BP

: 150/80 mmHg

HR

: 81 x/i

Cyanotic

RR

: 20 x/i

Dispnoe

Temp : 36,3oC

Oedem

: (-)
: (-)
: (-)

Generalized state
Head

Eye
Nose

: Conj palp inf anemic (-/-), icteric sclera (+/+)

: Epistaxis (-)

Mouth : Gingival bleeding (-)

Thorax

: Respiratory sound: Vesicular, Additional sound: (-)

Abdomen
Extremities

: Liver & Spleen not palpable

: Superior Inferior purpura (-)

Localised state
Abdomen

: Laxed, peristaltic (+)

Fundal Height

: 2 fingers below navel, strong contraction

Operative Wound

: Covered by sterile gauge, impression: dry

Vaginal Bleeding

: (-), lochia (+) rubra

Micturition

: (+) via catheter, UOP = 70 cc / hour, clear

Defecation

: (-), flatus (+)

Diagnosis

: Post CS d/t Severe preeclampsia + Partial HELLP syndrome +

Post Poomeroy sterilization + PD 5 + Thrombocytopenia + AKI
std risk

Therapy
:

IVFD RL 20 drops/minute

Inj Ceftriaxone 1 gr/12 hour

Metronidazole drips 500 mg/8 hour

Inj Ketorolac 30 mg/8 hour

Amlodipine 1x10 mg

Plan

:
Complete blood count 6 hours post transfusion

FOLLOW UP
Monday, 1st February 2016
Chief Complaint: Pain on the abdominal wound
Present State
Consc

: Alert

Anemic

: (-)

Icteric

: (-)
: (-)

BP

: 140/90 mmHg

HR

: 85 x/i

Cyanotic

RR

: 17 x/i

Dispnoe

Temp : 36,5oC

Oedem

: (-)
: (-)

Generalized state
Head

Eye
Nose

: Conj palp inf anemic (-/-), icteric sclera (+/+)

: Epistaxis (-)

Mouth : Gingival bleeding (-)

Thorax

: Respiratory sound: Vesicular, Additional sound: (-)

Abdomen
Extremities

: Liver & Spleen not palpable

: Superior Inferior purpura (-)

Localised state
Abdomen

: Laxed, peristaltic (+)

Fundal Height

: 2 fingers below navel, strong contraction

Operative Wound

: Covered by sterile gauge, impression: dry

Vaginal Bleeding

: (-), lochia (+) rubra

Micturition

: (+) via catheter, UOP = 70 cc / hour, yellow

Defecation

: (-), flatus (+)

Diagnosis

: Post CS d/t Severe preeclampsia + Partial HELLP syndrome +

Post Poomeroy sterilization + PD 6 + Thrombocytopenia + AKI
std risk

Therapy
:

IVFD RL 20 drops/minute

Inj Ceftriaxone 1 gr/12 hour

Metronidazole drips 500 mg/8 hour

Inj Ketorolac 30 mg/8 hour

Amlodipine 1x10 mg

Plan

:
a

THANK YOU