LAPORAN KASUS

Patients ID

Name : Mrs. E
Age : 23 yrs
Address : Kel. Batang Arau Padang
MR No. : 83.55.94
Education : Elementary school
Occupation : None
Admission Date : July 17th, 2013

Anamnesis

Chief Complaint:
A 23 years old patient was admitted to
the Delivery Room of Dr. M. Djamil
Central General Hospital on July 17th,
2013 at 12.00 am reffered from
Reksodiwiryo Hospital with D/ P1A0H1
post SCTPP day 4 of care

Present Illness History:

Patient was cared at ReksoDiwiriyo Hospital and

got a CS surgery 4 days ago on indication of
Contracted Pelvic Primary CS on 3rd day, patient
got a dyspnoe and getting heavier.
Patient got blood transfusion (3 Unit) at
Reksodiwiriyo Hospital due to anemic condition
(Hb 6,8 gr%)
Since this morning patient have a dyspnoe and
become heavier than before and got referred to
M.Djamil Hospital with IV Line and catheter.
This is 1st pregnancy
Urinary and Fecal was Normal

Previous Illness History:

There was no previous history of heart,
liver, kidney, allergy, DM and
hypertension.
Family Illness History:
There was no history of hereditary
disease, contagious and phsycological
illness in the family.

Occupation, Socioeconomics,
Psychiatry, and Habitual History:
Marriage history: (-)
History of pregnancy/abortion/delivery:
1/0/0
1. 2013, male, 3200 gr, term pregnancy, CS

on indication of Contracted Pelvic Primary

CS, Doctor at Reksodiwiryo Hospital, dead

History of family planning: (-)

History of immunization: (-)

Physical Examination
Gen

Conc

BP

HR

RR

Mod CMC

160/100

120

30 37

BH

BMI

BW

UAC

146
86 40,37
28
Patellar reflex : +/+ (N)
Proteinuria by burning : ++
D/ P1A0L0 Post TPPCS on indication of Contracted
Pelvic Primary CS + severe preeclampsia +
Anemia + Dyspnoe ec ALO Suspected

Management
Initial dose MgSO4 regiment

12.00 am : started initial dose of

MgSO4 regimen

12.15 pm : finished initial dose of

MgSO4
regimen
followed
by
maintenance dose

Physical Examination :
GA ConsBP PR RR T
Mdt CMC 150/90 100x 20x 37

Eyes : Conjunctiva wasnt anemic, Sclera

wasnt icteric
Neck : JVP 5-2 cmH2O,
thyroid gland no enlargement
Chest : H/L normal
Abdomen : OR (obstetric record)
Genitalia : OR (obstetric record)
Extremity : Edema -/-,
Physiological Reflex +/+,
Pathological Reflex -/-

Obstetric Record :
Abdoment
Inspection
: a little bit enlarge, scar (+)
Pfannenstiel incision
Palpation : Uterine fundal height was 3 fingers
umbilicus, uterine contraction was moderate.
Percussion : Tympani
Auscultation : Peristaltic sound was normal

below

D/ P1A0L0 Post TPPCS on indication of Contracted Pelvic

Primary CS in MgSO4 regiment Maintenance dose +
Partial HELLP Syndrome + Anemia + Dyspnoe ec ALO
Suspected

Management :

Controlling general condition, vital sign, Vaginal Bleeding,

Fluid balance, Patella Reflex
IVFD RL 10 gtt/mnt (12 hour/kolf)
MgSO4 1 gram/hour
Ceftriaxone Inj. 2x1 Amp
Metronidazole 3x500 mg
Dexamethasone inj :
1st day : 2x2 Amp
2nd day : 2x1 Amp
Lasix Inj. 2x1 Amp
Consult to interne, cardiology and opthalmology

Laboratory Result July 17th 2013

: No. Parameter
Result
Normal Range
1

Haemoglobine

7,7/dl

12.-14

Haematocryte

24%

37-43

3.

Leucocyte

26,3.1 103/mm3

5-10

4.

Trombocyte

360.103/mm3

150-400

5.

MCH

26,8 pg

27-31

6.

MCV

83 um3

82-92

7.

MCHC

32,3 g/dL

32-36

8.

APTT

35,7

29,2-39,4

9.

PT

12,6

10-13,6

10.

INR

1,1

0-1,2

No.

Parameter

Result

Normal range

Protein Total

6,0 g/dl

6.0-7.8

Albumin

3.1 g/dl

3.5-5.2

Globulin

2.9 g/dl

0.0-0.0

SGOT

25 u/L

0.0-31.0

SGPT

36 u/L

0.0-34.0

Ureum

93 mg/dl

15.0-40.0

7
8

Creatinin
Calsium

3,7 mg/dl
7,6 mg/dL

0.6-1.2
8,6-10,3

Total Bilirubin

0,44 mg/dL

0,1 1,2

10

Random Blood Glucose

127

<180

11

LDH

1764 u/l

<480

Urine
Parameter

RESULTS

Normal range

PROTEIN
GLUCOSE
LEUKOSIT
ERITROSIT
KRISTAL
EPITEL
UROBILINOGEN
BILIRUBIN
SILINDER

++
17-18 / LPB
2-3 / LPB
NEGATIVE
GEPENG
POSITIVE
NEGATIVE
HYALIN 3-4
GRANULAR 2-3

NEGATIVE
NEGATIVE
0-5 LPB
0-1 LPB
NEGATIVE
GEPENG
POSITIVE
NEGATIVE
NEGATIVE

No.

Parameter

Result

Normal range

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17

pH
pCO2
pO2
Na+
K+
Ca++
Hct
Temp Corrected
Ca++
HCO3HCO3Std
TCO2
BEecf
BE(B)
SO2c
THbc
THb

7,42
31 mmHg
76 mmHg
141 mmol/L
3,8 mmol/L
0,86 mmol/L
15 %
37 oC
0,87 mmol/L
20,1 mmol/L
22,1 mmol/L
21,1 mmol/L
-4,4 mmol/L
-3,5 mmol/L
95 %
Null
7,7 g/dL

7,37 7,43
36-44
92-96
135-145
3,5-4,5
1,12-1,32
36-38

Consult result from Internal

department
A/

- CHF Fc Class IV ec ALO

- Susp. CKD St III dd AKI
- Moderate Anemia ec post OP
- Leucocytosis ec Post OP dd Bronchopneumonia
- Susp. PEB

Th/

- IVFD Dextrose 5% 12 hours/day

- Lasix Bolus 2 Amp IV, continue up to 2x1 Amp IV
- Antibiotic according to ObGyn
- Fluid balance
- Candesartan 1x8 mg
- Check the reticulocyte and sputum cultur, Ureum, Creatinin,
Hb, Leucocyte.
- Intensive care
- Join care by Cardiology, Pulmonology, Hematology, and Renal
Hypertension SubDivision

Consult result from Cardiology

Department

A/ P1A0H0 Post TPPCS day care 4th +

Severe Preeclampsia + Anemia +
Hypertension Stage II
There is no acute and emergency
condition in cardiology
Th/ Methyldopa 3x250 mg

Consult result from Opthalmology

department

There are moderate eclamptic fundal

sign

Th/ According to Obgyn

Consult result from Pulmonology

department

A/ ALO + P1A0H0 post TPPCS + Severe

Preeclampsia + Anemia
Th/ - Lasix Inj. 1x1 Amp
- KSR
- Fluid balance
- Re check astrobe and re consult if
there is new result

Consult to consultant, advice :

Consult to High Risk Consultant
antibiotics : Ceftriaxone 2x2 gr

Metronidazole 3x1 tab

Consult to High Risk consultant, advice :

SM Regiment 1gr/hr
Lasix 2x1 Amp IV
Re consult to ICU after 3 hours NRM

Join care with Cardiology, Pulmonology,

opthalmology, and Internist

July, 18th 2013

08.30 am

Anamnestic

- Fever (-), Urination (+)with catheter, Defecate (-), Breast milk(-), Headache (-), Epigastrium pain (-), Blurred
vision (-)

Physical Examination

Vital sign :
General appearrance : Moderate
Conciousness
: Composmentis
Blood pressure
: 130/90 mmHg
Heart rate
: 84 x/m
Respiratory rate
: 26 x/m
Body Temperature
: 37 C

Abd
:
Inspection
: a little bit enlarge, sicatrix (+)
Pfannenstiel
Palpation
: Uterine fundal height was 3 fingers below umbilicus, uterine
contraction was moderate.
Percussion
: Tympani
Auscultation : Peristaltic sound was normal\
Gen
: I : V/U normal, vaginal bleeding was abscent
Vaginal Toucher :
complete
Amnionic sac (-), clear residu
Head palpated anterior occiput at HI-II

Diagnose

D/ P1A0L1 Post TPPCS on indication of Contracted Pelveic Primary CS in Sm regiment Maintenance dose +
Partial HELLP Syndrome + Anemia + Dyspnoe ec ALO Suspected

Management

Controlling general condition, vital sign, Vaginal Bleeding, Fluid balance, Patella Reflex
IVFD RL: Gelofusin 1:1. 10 gtt/mnt (12 hour/kolf)
MgSO4 1 gram/hour
Ceftriaxone Inj. 2x1 Amp
Metronidazole 3x500 mg
Dexamethasone inj : 2x1 amp
Lasix Inj. 2x1 Amp

Follow Up Interne Department:

Follow up ophtamology department
Moderate Eclamptic fundal sign
Th/ According Obgyn dept
Sub department Cardiology Interne:
CHF Fc IV RVH LVH ec susp
Cardiomiopathy with ALO
A/ Drip lasix 5 amp in 50 cc NaCl 0,9%
(with syringepump)
Lasix 2x1 amp stoped
Sub Department Hematology Interne
d/ Mild Anemia Normositik Normochrome
ec acute hemoragic
a/ Check Hb, Ht, Trb, MCV,MCH,MCHC,
Reticulosyt, )
Check PT,APTT, D-Dimer
Transfusion PRC

Sub Department Gastrohepatology

Abdomen: Hepar and lien was not
palpable
Labor: SGOT : 18
SGPT : 25
Total bilirubin : 0,44
a/ There is no abnormalty in Hepar
phisiology in this patient
Follow up Cardiology Department

There is no acute and

emergency condition in
cardiology

Th/ Methyldopa 3x250 mg

Pulmonology Department
CHF Fungsional grd IV LVH + RVh
+ ALO

Follow Up
Day/Date

Friday, 19-7-2013

Fever (-), urinate

(+) cath, defecate
(-), breast milk (-),
vaginal bleeding
(-), headache (-),
blurred vision (-),
epigastric pain (-)

PE
GA : moderate,
Conc : CM, BP :
132/73, PR :
88x/, RR : 24x/,
temp : 36.7 Abd :
No distension,
wound insicion
healing, UFH
accordance to
umbilicus,
contraction (+)
Genetalia :
V/U normal,
vaginal bleeding
(-)
Fluid balance :
Input : 2000 cc
Output : 7200 cc

D
P1A0H0
post CS ec
primary CS
contracted
pelvic +
severe
preeclampsi
a on regimen
SM
maintanance
dosage +
partial
HELLP
syndrome +
anemia +
dyspneu ec
susp. ALO,
day 6th

Planning/Therapy
-Evaluate GA,VS,VB
-Mobilization
-Diet HCHP LS
-Breast care
-Vulva hygiene
-Ceftriaxone inj. 2x2 gr
iv
-Metronidazol inf 500
mg 3x1
-Lasix drip on 50 cc
NaCl 0.9% 2.5cc/hr
-Mofor 0.1 cc/hr
-Candesartan 1x8 mg
-Farbiven nebulizer 1
fl/4 hr
-RL : Gelofusin 1:1 10
drops/min

Other departements

Pulmonologist
Cough(-), gasping (-)
Dx : ALO on healing progress
Planning : Chest X-Ray
Therapy :
lasix 1x1 amp inj. iv.
Ambroxol tab 30 mg 3x1

Internist (sub-cardio)
Gasping (), fever (-), cough (-)
Dx : CHF Fc III LVH RVH + ALO on healing progress
Therapy :
Drip lasix 1 cc/hr
Stop farbiven

Resident sub-hematologist and resident sub-kidney/hypertension

did not follow up this patient.

Follow Up
Day/Date
Saturday, 20-72013

A
Fever (-), urinate
(+) cath, defecate
(-), breast milk (-),
vaginal bleeding
(-), headache (-),
blurred vision (-),
epigastric pain (-)

PE
GA : moderate,
Conc : CM, BP :
142/78, PR :
85x/, RR : 23x/,
temp : 36.8 Abd :
No distension,
wound insicion
healing, UFH 3
fingers below
umbilicus,
contraction (+)
Genetalia :
V/U normal,
vaginal bleeding
(-)
Fluid balance :
Input : 1500 cc
Output : 3900 cc

D
P1A0H0
post CS ec
primary CS
contracted
pelvic +
severe
preeclampsi
a finished
regimen SM
+ partial
HELLP
syndrome +
anemia +
ALO on
healing
progress,
day 7th

Planning/Therapy
-Evaluate GA,VS,VB
-Mobilization
-Diet HCHP LS
-Breast care
-Vulva hygiene
-Ceftriaxone inj. 2x2 gr
iv
-Lasix drip on 50 cc
NaCl 0.9% 2.5cc/hr
-Candesartan 1x8 mg
-RL : Gelofusin 1:1 10
drops/min

Other departements

Pulmonologist
Cough(+), gasping (+) minimal
Chest X-Ray : healing progress
Dx : ALO on healing progress
Planning : check CBC
Therapy :
Azythromicin 1x500 mg

Internist
(sub-cardio)
Gasping (+) minimal, fever (-), cough (+)
Dx : CHF Fc III LVH RVH + ALO on healing progress
Therapy :

Drip lasix 1 cc/hr

Farbiven/6 hr

(sub- hemato)
Bleeding (-), anemia
Dx : mild anemia normositik normokromik ec susp. Hemolytic
Planning : comb test

Resident sub-kidney/hypertension did not follow up this patient.

Follow Up
Day/Date
Sunday, 21-72013

A
Fever (-), urinate
(+) cath, defecate
(-), breast milk (-),
vaginal bleeding
(-), headache (-),
blurred vision (-),
epigastric pain (-)

PE
GA : moderate,
Conc : CM, BP :
120/70, PR :
92x/, RR : 22x/,
temp : 36.8 Abd :
No distension,
wound insicion
healing, UFH 4
fingers below
umbilicus,
contraction (+)
Genetalia :
V/U normal,
vaginal bleeding
(-)
Fluid balance :
Input : 2000 cc
Output : 2500 cc

D
P1A0H0
post CS ec
primary CS
contracted
pelvic +
severe
preeclampsi
a finished
regimen SM
+ partial
HELLP
syndrome +
anemia +
ALO on
healing
progress,
day 8th

Planning/Therapy
-Evaluate GA,VS,VB
-Mobilization
-Diet HCHP LS
-Breast care
-Vulva hygiene
-Ceftriaxone inj. 2x2 gr
iv
-Azytromicin 1x 500 mg
-Lasix drip on 50 cc
NaCl 0.9% 2.5cc/hr
-Candesartan 1x8 mg
-RL : Gelofusin 1:1 10
drops/min

Follow Up
Day/Date
Monday, 22-72013

A
Fever (-), urinate
(+) cath, defecate
(-), breast milk (-),
vaginal bleeding
(-), headache (-),
blurred vision (-),
epigastric pain (-)

PE
GA : moderate,
Conc : CM, BP :
120/80, PR :
84x/, RR : 22x/,
temp : 36.8 Abd :
No distension,
wound insicion
healing, UFH 4
fingers below
umbilicus,
contraction (+)
Genetalia :
V/U normal,
vaginal bleeding
(-)
Fluid balance :
Input : 2000 cc
Output : 2000 cc

D
P1A0H0
post CS ec
primary CS
contracted
pelvic +
severe
preeclampsi
a finished
regimen SM
+ partial
HELLP
syndrome +
anemia +
ALO on
healing
progress,
day 9th

Planning/Therapy
-Evaluate GA,VS,VB
-Mobilization
-Diet HCHP LS
-Breast care
-Vulva hygiene
-Cefixime tab. 2x200
mg
-Azythromicin 1x500
mg
-Candesartan 1x8 mg
-Antalgin tab 3x500mg
-SF tab 1x1
-Vit C tab 1x1
-Metyldopa tab
3x250mg
-Linoral tab 2x1
-Move to ward room

Follow Up
Day/Date
Tuesday, 23-72013

A
Fever (-), urinate
(+) cath, defecate
(-), breast milk (-),
vaginal bleeding
(-), headache (-),
blurred vision (-),
epigastric pain (-)

PE
GA : moderate,
Conc : CM, BP :
120/80, PR :
82x/, RR : 20x/,
temp : 36.7 Abd :
No distension,
wound insicion
healing, UFH 4
fingers below
umbilicus,
contraction (+)
Genetalia :
V/U normal,
vaginal bleeding
(-)

D
P1A0H0
post CS ec
primary CS
contracted
pelvic +
severe
preeclampsi
a finished
regimen SM
+ partial
HELLP
syndrome +
anemia +
ALO on
healing
progress,
day 10th

Planning/Therapy
-Evaluate GA,VS,VB
-Mobilization
-Diet HCHP LS
-Breast care
-Vulva hygiene
-Cefixime tab. 2x200
mg
-Azythromicin 1x500
mg
-Candesartan 1x8 mg
-Antalgin tab 3x500mg
-SF tab 1x1
-Vit C tab 1x1
-Metyldopa tab
3x250mg
-Linoral tab 2x1

Other departements

Internist
(sub-cardio)
Gasping (-), edema (-)
Dx : CHF Fc I-II LVH RVH + ALO on healing

progress
Therapy :
Lasix tab 1x40 mg
Dulcolax tab 1x2 (evening)
Cardio II diet