department

Consult to obsgyn 22.30

hospitalized day 17

Latest condition october 16th 2014

S) Patient on ventilator mode SIMV,
O) STU : CM GCS : 4-X-6
BP :
HR : 112 RR : 19x/m on ventilator SIMV Temp :
36,7
P : ves (+) rh +/+ wh +/+
Abd :supel, BU(+), l
STG : v/v fluksus (-)
Input =cc/ 24 jam
output=
cc/24 jam
A) Post salphingectomy (s) due to pregnancy rupturer tuba pars
ampularis (s) + severe bilateral pneumonia + Sepsis +
increase LFT POD 18

P): pro Tracheostomi

other therapy ~ TS Pulmo
-

O2 ventilator~ TS Anestesi
Diet sonde 4x200 cc/24jam
Inj Levofloksasin 750 mgIV
Inj. Meropenem 3x1g iv
Tamoliv 3 x 1 gr
Nebule combivent
Oral/personal higiene

2. Mrs. Mahmudah/35 y.o / hospitalized october 9th

2014 /04.00 WITA
P3A0 post SC H-6 a/i (severe
preeclampsia+IUGR+abnormal NST) + Eklampsia +
penurunan kesadaran + HELLP syndrome + AKI +
MODS + sepsis + history solutio plasenta + history
S)
O)
consiousness
cardiac
arrest
GCS:1-1-2
BP: 115/67mmHg
HR: 142x/m

RR: 24x/m
T: 36,8 C

STO: FH ~ 3 fingers under umbilicus

contraction (+)
v/v fluxus (-)
input:
output:

cc/ jam
cc/jam

Result of head CT Scan :

Cerebral and Cerebellar in normal limit
Problem list ;
Post SC
Eclampsia
Decrease of consciousness
Hellp syndrome
AKI
MODS
Sepsis

 P) consult interna for HD Cito

join Neurologi
waiting result blood and urine cultur

RD5 1000cc/24 jam

Diet Entramix 6x100 cc
Lasix 5 mg/jam (sp)
Inj. Ceftazidime 3x1 g
Alinamin F 3x1 amp
Phenitoin 2x1 amp
PO: Nifedipin 3x10 mg
Metildopa 3x250 mg

examinat
ion

13/10

Hemoglo
bin

11.6

g/dl

Leucocyt
e

16.1

ribu/ul

Eritrocyt
e

4.01

juta/ul

Hematoc
rite

38.8

vol%

Tromboc
yte

247

ribu/ul

SGOT

136

146

U/I

SGPT

208

148

U/I

GDS

124

202

mg/dl

Ureum

111

235

mg/dl

Creatinin

1.4

2,8

mg/dl

Natrium

145

155

mmol/L

Kalium

4.4

3,7

mmol/L

Chlorida

109

115,8

mmol/L

3,8

g/dl

Albumin

Satuan
15/10

Urinalisa
Warna
kekeruhan

Tanggal 15/10
Kuning ag keruh

Proteinalbumin

+1

Darah samar

+3

Leukosit

3-5

Erythrosit
Bakteri
Lain-lain

20-25
+1
Jamur +1