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Kasus nomor

Identity

•Name : Mrs R
•Age : 24 yo
•Adress : Padang
•MR : 994059
•Date of entrance : Oct 21th 2017
ANAMNESIS
• A 24-year-old female patient admitted to IGD
RS M Djamil Padang on 21th October 2017 at
22.10 WIB post from Painan Hospital with
diagnosis G1P0A0H0 35-36 weeks preterm
pregnancy + PPROM + Uncontrolled
hyperthyroidism
Present history Illness
• Previously the patient was known to suffer from hyperthyroid
since 3 years ago, but not regularly treatment, last control 1
year ago and get therapy PTU and propanolol
• 4 days ago while control to obstetrician, patients get therapy
PTU 3 x 1 tab a day, then the patients plans for control to
intenist on monday on 23/10/2017 due to her hypertiroidism
• Fluid leakage from the vagina (+) since 36 hours ago, soaking 1
piece of small blanket, fishy
• Pelvic pain to the groin was absent
• Bloody show from the vagina was absent
• A lot of blood out of the genitals (-)
• There was no massive vaginal bleeding
• Amenorrhea since ± 8,5 months before
• HPHT : 23 / 2/ 2017 TP : 30/11/2017
• Fetal movement was felt since 4 months ago.
• No complain of nausea, vomiting and vaginal bleeding neither during early
pregnancy nor late pregnancy.
• Prenatal care to midwife in primary health care was routine 5x since 4,5,6,7,dan 8
mont of pregnancy and to obstetrician 1x on 8 month pregnancy
• Menstruation History : menarche at 13 years old, irregular cycle, once a month,
last for 5 to 7 days, 2-3 times pad change/day without menstrual pain
• Feel nervous, moody, weak, or tired were present
• Have hand tremors (-), fast or irregular heartbeat (-), or have trouble
breathing even when you are resting(-)
• Feel hot (+), sweat a lot (+), have warm and red skin (-) itchy (-).
• Have frequent and sometimes loose bowel movements (+)
• Have fine, soft hair that is falling out (+)
• Lose weight even though eating normally or more than usual (+).
Previous Illness History
There was no previous history of heart, lung, liver, kidney, DM,
hypertension, and allergic reaction to the drugs.

Family Illness History


There was no history of hereditary disease, contagious and
physicological illness in the family.
Marital history : once in 2016

History of pregnancy/abortion/delivery: 1/0/0


1. Present pregnancy

Educational history : senior high school


Occupational history : housewife
Contraception history : (-)
Immunization history : (-)
History of habit : Smoking (-), alcohol (-), drug abuse (-)
Physical Examination
GC Cons BP HR RR Temp
Mdrt CMC 120/80 140 20 36,7

Body Weight before pregnant : 49 kg


Body weight after pregnant : 58 kg
Tinggi Badan : 153 cm
BMI : 20.93 kg/m2 normoweight
Arm circumference : 25 cm
Eye : Anemic conjunctiva (-), Icteric sclera (-)
Neck : JVP 5-2cmH2O
• Thorax :
Cor :
Inspection : ictus cordis were not visible
Palpation : ictus cordis were not palpable
Percution : cor limits were in normal limit
Auskultation : heart rate were normal, murmur (-)
Pulmo :
Inspection : respiration movement left = right
Palpation : fremitus left = right
Percution : sonor
Auscultation : Rh (-/-) wh (-/-)
• Abdomen : Obstetric record
• Genitalia : Obstetric record
• Extremity : Edema -/-, Patella ref +/+ N, Pathologic ref -/-
Obstetric record
Abdomen
Inspection : Seems enlarged accordance to 8 month pregnancy
Palpation :
L1 : Uterine fundal was palpated ½ proc. xyphoid umbilical, a
large soft noduler mass was palpated
L2 : The largest resistance was felt on the left side,
Small structures of the fetus were felt in the right side
L3 : A hard, round mass was palpated, floating
L4 : Do not perform
Fundal height : 27 cm EBW : 2170 gr
Uterine contraction : -
Percussion : thympany
Auscultation : peristaltic sound was normal, FHR : 145-158 bpm
Genitalia : I : Vulva & urethra were normal
Vaginal bleeding (-)
• Inspekulo :
• Vagina : tumor (-), laseration (-), fluxus (+), a clear
liquid on forniks posterior.
• Portio : NP, size as a head finger of adult hand , tumor
(-), laseration (-), fluxus (+), a clear liquid were leaking
from canalis cervikalis, OUE were closed.
USG IGD
• Single fetal live intra uterine head presentation
• Fetal movement activity is good
• Biometry
BPD: 87.3mm FL: 66.7 cm
AC: 291mm EFW: 2275gr
• The placenta embedded in the fundus extends into the front corpus
• Impression:
• Single fetal live gestational age 34-35 weeks
CTG
• Baseline : 140-155 bpm
• Variabilitas : 5-15
• Akselaration : (+)
• Deselaration : (-)
• Fetal movemen : (+)
• Impression : CTG Reaktif
LABORATORIUM 21/10/2017

• Hemoglobin : 13,5 g/dl


• Leukosit : 10.880 / mm3
• Hematokrit : 38%
• Trombosit : 190.000 / mm3
• PT :10,5 sec
• APTT : 38,3 sec
• GDS : 78 mg/ dl
Lab
• Na/K/Cl/Ca : 141/4,1/109/9,0
• Protein total : 6,0 g/dl
• Albumin/ globulin : 3,3 g/dl
• Bilirubin total : 0,7 mg/dl
• Bilirubin direct/indirect : 0,3 / 0,4 mg/dl
• SGOT/SGPT : 19 / 17 u/l
• LDH : 316 u/l
Urinalisa
• Leukocite : 1-2 / LPB
• Eritrocite : 2-3 / LPB
• Silynder : (-)
• Cristal : (-)
• Epitel : (+) gepeng
• Protein : (-)
• Glucosa : (-)
• Bilirubin : (-)
• Urobilinogen : (+)
Diagnosis:
G1P0A0H0 gravid preterm 34-35 weeks + PPROM + uncontrolled
hyperthyroidism
Fetal alive singelton intrauterine

Plan

Expectative
Controls KU, VS, BJA, His
Informd concent
Regular blood lab
The intern and heart consul
Results of cardiac consul
A / Hipertiroid heart disease can not be excluded
P/
Echocardiography when the condition is stable
Monday
Check out the complete lab
If the lab is within normal limits goldman score 4 point (class 1, low
risk, 1% complication)

3/16/2019
Internist consult
Indeks wartofsky : 30
Indeks wayne : 24
Indeks new castle : 48

A/ struma difusa toxica


G1P0A0H0 34-35 weeks gravid

P/ PTU 3x 100mg
Propanolol 2x10mg
Chek faal tyroid FT4, T3, TSH, USG tiroid, Echo
Theraphy
• IVFD RL 20 tpm
• Inj. Dexametason 2x2 amp
• Inj. Ceftriaxon 2x1gr
• Propanolol 2x10mg
• PTU 3x100mg
• Vit C 3x1
• Calac 1x1
• USG fetomaternal
Follow up 22/10/2010
S/
• Pelvic pain to the groin (-)
• Fetal movement (+)

GC Cons BP HR RR T
O/
Moderate Alert 110/70 88 21 36,7
Abdomen:
• His :-
• FHR : 138-148 bpm

Genitalia
• Inspection : V/U normal , PPV (-)

A/
• G1P0A0H0 gravid preterm 34-35 weeks + PPROM + uncontrolled hyperthyroidism
• Fetal alive singelton intrauterine
Therapy
• IVFD RL 20 tpm
• Inj. Dexametason 2x2 amp
• Inj. Ceftriaxon 2x1gr
• Propanolol 2x10mg
• PTU 3x100mg
• Vit C 3x1
• Calac 1x1
• USG fetomaternal tomorrow 23/10/2017
Follow up 23/10/2010
S/
• Pelvic pain to the groin (-)
• Fetal movement (+)

GC Cons BP HR RR T
O/
Moderate Alert 120/70 85 22 36,7
Abdomen:
• His :-
• FHR : 145-155 bpm

Genitalia
• Inspection : V/U normal , PPV (-)

A/
• G1P0A0H0 gravid preterm 34-35 weeks + PPROM + uncontrolled hyperthyroidism
• Fetal alive singelton intrauterine
Theraphy
• IVFD RL 20 tpm
• Inj. Dexametason 2x2 amp
• Inj. Ceftriaxon 2x1gr
• Propanolol 2x10mg
• PTU 3x100mg
• Vit C 3x1
• Calac 1x1
• USG fetomaternal today
USG Fetomaternal
Ekspertise USG
• Fetal alive singelton head presentation
• Fetal movement activity is limited
• Biometry
BPD: 8.4 cm FL: 6.4 cm EFW: 2243 gr
AC: 29.72 cm HC: 5.73 cm
• AFI: amniotic (-)
• SDAU: 1.58
• The placenta is embedded in the fundus grade II-III
• Impression: preterm 33-34 weeks pregnancy
oligohydramnios
Plan:
Candidate for elective SC tomorrow 24/10/2017
Lab faal tyroid
• T3 : Reagen was empty
• T4 : Reagen was empty
• TSH : 0,001mIU/ml (N = 0,25-5)
• FT4 : Reagen was empty
24/10/2017
SCTPP performed, baby boy was born
BBL: 2600gr
PB: 44cm
A / S: 8/9
The placenta is born complete with a slight on the umbilical cord,
weighs about 450 grams, 40cm long cord length, 14x13x2cm size,
parasentralis cord insertion
Bleeding during the action is about 250cc
A / P1A0H1 post SCTPP oi uncontrolled hyperthyroid + oligohydramnios
Mother and child were in care
P/
Tigh monitoring GC, VS, PPV
Routine blood check 6 hours post op
Inj. Ceftriaxon 2x1gr
Propanolol 2x10mg
PTU 3x100mg
Vit C 3x1
Calac 1x1
6 hours post Op laboratory 24/10/2017
• Hemoglobin : 12,9 g/dl
• Leukosit : 15.130 / mm3
• Hematokrit : 38%
• Trombosit : 228.000 / mm3
• T4 total : 228,93nmol/L ( N= 60-120 )
Followup 25/10/2017
S/ fever(-), palpitation (-), PPV (-)
O/
GC Cons BP HR RR
Moderate Alert 120/70 85 22 36,7

Abd : Distension (-) wound were cover by verban, wound was good
Gen : V/U normal, PPV (-)
A/ P1A0H1 post SCTPP oi uncontrolled hyperthyroid + oligohydramnios
Mother and child were in care
P/
Tigh monitoring GC, VS, PPV
Routine blood check 6 hours post op
Inj. Ceftriaxon 2x1gr
Propanolol 2x10mg
PTU 3x100mg
Vit C 3x1
Calac 1x1
Terima Kasih
Foto Bayi

3/16/2019
Grafik

3/16/2019

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