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New patient
Prior patient
:
:
1 patient
- patient
: Unconsciousness (alloanamnese)
E
: Experienced by patient since 8th May 2016 at 10.30
am. History of seizure (+), twice, first at home and followed
with unconsciousness and the second one when arrived at
Adam Malik General Hospital for 2 minutes. History of
hypertension disease (-), History of Gestational Hypertension in
previous pregnancy (-), History of Gestational Hypertension in
this pregnancy (?), History of epigastric pain (?), headache (?),
nausea and vomitus (?), blurred vision (?). Patient was referred
from Amanda Hospital, Berastagi, with diagnose Eclampsia +
unconsciousness + lung edema + Second gravide + live fetus.
Patient was managed by anesthesiologist first to improved
generalized state with ETT attached
Previous illness
: Previous medical history
: MgSO4 20% 10 ml (4 gr)
Loading
MgSO4 40% 40 ml (12 gr) 14
gtt/I
Inj. Dexametasone 15 mg
Last Menstrual Periode
: ? August 2015
Estimated Due Date : ? May2016
ANC
:?
Obstetric History :
1.Death
2.Current pregnancy
Vital Sign
Cons : Somnolence
BP
Pulse
RR
Temp
:
:
:
:
Anemic
: (-)
Localized state :
Head : Eye : Conjuctiva palpebra anemia(-)/(-),
Sclera : icteric (-)/(-)
Neck : Limph node enlargement (-)
Cor
: S1 = S2, additional sound (-)
Thorax
: Respiratory sound
Additional sound
Ronchi (+)/(+)
: Vesicular
: Wheezing(-)/(-),
Obstetrical state
Abdomen
: Symetrically enlarged
Fundal Height
Lowest Part
: Head
Uterine contraction
: (-)
Fetal movement
: (+)
: 38.410
: 41,0
: 446.000
: 129.00
N : 12-14 gr/dl
N : 4000-11000 /mm
N : 36,0 - 42,0 %
N :150.000-400.000/mm3
N : < 200 mg/dL
Albumin
: 2,9
APTT
PT
Trombin Time
INR
: 12,60
: 42,50
: 13,5
: 15.5
C = 33,8 S
C = 14,0 S
C = 17,3
: 0.97
Ureum
Creatinin: 0,72
BUN
: 19,00
Natrium
Kalium
Cloride
: 137
: 3,2
: 107
:9
N : > 50 mg/dl
N : 0,6-1,2 mg/dl
N : 7 - 19
N :135-155
N : 3.6-5.5
N : 96-106
pH
pCO2
pO2
HCO3
CO2
Total
BE
O2 Saturation
: 7,230
: 20
: 186,0
: 8,4
: 9,0
: - 17,1
: 99,0
N : 7,35- 7,45
N : 38 - 42
N : 85 - 100
N : 22- 26
N : 19 25
N : (-2) (+2)
N : 95 - 100
USG TAS
USG TAS
Single Fetus, alive
Fetal Heart rate (+), Fetal Movement (+)
BPD
: 88 mm
AC
: 258,9 mm
FL
: 57,1 mm
AFI
: 9 cm
Placenta
: Corpus anterior, grade II
Conclusion
completely
Uterine cavity was cleaned with sterile gauss
Uterine was hecting with hemostatic suture figure of eight,
continuously interlocking, overhectingn and reperitonealization
Dx
Th/
-
R/
-
THANK YOU