PATIENT 1

Mrs. H, 25 yo, P1A0, Bataknese, Moslem, Housewife, Senior High School

married with Mr. R, 29yo, Bataknese, Moslem, Bachelor, Employee . This
patient came to USU Hospital on March 25th 2020 at 110.00 am with :

Cc : Loss of conciousness

E : This has been experienced by the patient since 1 day before admitted to
hospital. Patient had SC on other hospital on Friday 20/3/2020 d/t gemelli.
History of premature rupture of membrane(+). History of elevated blood
pressure before pregnancy (-) but blood pressure before SC 160/100, Post
SC patient had PRC transfusion 3 bag. Micturition within normal limit via
catheter and defecation within normal limit.
• History Previous illness :-
• History Previous medication :-
• History of Surgery : SC (20/3/2020)
• LMP :-
• EDD :-
•

History of Pregnancy
Vital Sign
Sens : Apatis
BP : 160/100 mmHg
HR : 80 x/min
RR : 20 x/min
Temp : 36,5OC

General condition : Severe

Nutrition state : Moderate
Illness condition : Moderate

Generalized State :
Head : Pale palpebra conjuctiva inferior (-), icteric sclera (-)
Neck : Lymph node enlargement (-), thyroid gland enlargement (-)
Cor : Within no abnormality
Thorax : Respiratory sound : Vesicular (+/+)
Additional sound : Rales (-/-), Wheezing (-/-)
Genitalia externa : Within no abnormality
Superior Ext : Within no abnormality
Inferior Ext : Pretibial oedem : (-/-)
Obstetrical State
Abdomen : Laxed, peristaltic (+), abdominal tenderness(+)
Fundal Height : 1 fingers below navel, contraction
adequate
P/V : (-), Lochia rubra (+)
L/O : covered by bandages, dry(+)

Gynecological State
• Inspeculo : smooth portio, closed. Lochia (+) blood (-)
• Vaginal examination: UT > BW, tenderness(+), mass not found o/t
right and left adnexa
 Laboratorium Findings
On March, 27th 2020

Hb : 9,1 N : 12-14 gr/dL

Leucocyte : 17670 N : 4000-11000/uL
Hematocrite : 26,80 N : 36,0-42,0/%
Platelet : 200.000 N : 150.000-400.000/uL
MCV : 81,00 N: 81-99 fL
MCH : 27,50 N: 27-31 pg
MCHC : 34,00 N: 31-37 g/dL
Na : 136. N: 135-155 mEq/L
K : 3,80 N: 3,6-5,5 mEq/L
Cl : 107 N: 96-106 mEq/L
 Urinalysis
On March, 27th 2020
PH : 7,00 N: 5-8
Protein : Negative N: Negative
Glucose : Negative N: Negative
Bilirubin : Negative N: Negative
Keton : Negative N: Negative
Blood : Positive 3 N : Negative
Nitrit : Negative N : Negative
USG TAS
Diagnosis
Loss of consciousness ec. (?) + Post SC on other hospital d/t gemelli +
Preeclampsia + NH5 + Sepsis

Therapy
- IVFD RL 20 dpm
- Inj MgSO4 20%  20 cc bolus
- Inj. MgSO4 40%  30 CC  14 dpm
- Inj. Ceftriaxone 1gr / 12 hours
- Inj. Ranitidine 1 amp / 8 hours
- Paracetamol drip / 8 hours

Plan
Reported to supervisor on duty dr. Yudha Sadewo ,M.Ked (OG), SpOG 
apadvice : ICU care, consul anasthesi, consul internist, check serial HB at
15.00 wib, check albumin
THANK YOU