Intensive Care Unit Report

Friday, November 19th 2021

Consultant:
Dr. dr. Rima Irwinda, OBGYN(C)

Residents:
Andro - Erfenes/ Tama - Victor / Erik - Tita / Angel - Naomi / Made - Zacky
1 Patient
No Patient
ER 1st Floor - Neurology division
Mrs. R, 19 yo 1.
MR 4550620
1 2.
Decreased consciousness due to
hydrocephalus et meningitis susp. 3.
TB at G2P1 24-25 weeks of
gestational age, singleton live 4.
intrauterine, electrolyte imbalance,
elevated transaminase enzymes,
iron deficiency anemia
Today’s Problem
Decreased consciousness due to
hydrocephalus et meningitis susp. TB
Electrolyte imbalance hyponatremia
(133), Hypokalaemia (3)
Elevated transaminase enzymes
(110/230)
Iron deficiency anemia (10.1)
 Today’s Condition
19 September 2021 06.00 AM
th
Fluid Balance
ER 1st floor 18/11/21 – 19/11/21
06.00 – 06.00
S: Inadequate contact

O: Moderately ill, GCS E3M5V2 Input 2700 ml

BP 124/82 mmHg (MAP 96), HR 98 x/min, Temp 36.7 oC, RR 20 x/min 2484 ml
SpO2 99 % on room air Output
Balance + 216ml
General Status
Eye: CA -/-, SI -/-, pupil anisocoria (3mm/6mm) Diuresis 1.2 ml/kg/h
Neck: nuchal rigidity (+)
Heart: S I/II regular, murmur (-), gallop (-)
Lung: vesicular (+/+), rhonchi (-/-), wheezing (-/-)
Abdomen: bowel sound (+) N, tenderness (-)
Extremity: warm, CRT < 2”, edema (-)

Obstetric status
Contraction negative, FHR 158 bpm
I: vulva/urethra wnl, active bleeding (-)
 Vital Chart
August 18th – 19th 2021
06.00 – 06.00

200
180
160
140
120
100
80
Sistolic
60 Diastol
40 ic
HR
20 RR
0 Temp
:00 :00 :00 :00 :00 :00 :00 :00 :00 :00 :00 :00 :00 Sat O2
6 8 10 12 14 16 18 20 22 0 2 4 6
 Lab 18/11/21 18/11/21 Normal value
00.40 07.54
CBC 10.1/27.3/12470/394000 12-15/36-46/4-10/150-410//82-
92/27-31/32-36
Diff Count 0.1/0/84/7.5/8.4/7.5/8.4 0-2/1-6/40-80/2-10/20-40
PT/aPTT 9.8-11.2/31-47
RBG 133 60-140 mg/dL
Na/K/Cl 130/3/95.5 133/3/98.4 136-145/3.5-5.1/98-107
Blood Ca/Ca2+ Ion -/1.12 8.4-10.2/1.01-1.31

Fibrinogen 430.3 200-400

d-Dimer 1280 <440
OT/PT 108/218 110/230 26/33
Ur/Cr 18.9/ 23.3/0.3 15-40/<1
Anti HCV/Anti HIV/HbsAg NR/NR/NR Non reactive
Albumin 3.5 3.5-5.2
CRP/PCT 29.8/0.16 <5.0/<0.05
Ferritin 51.93 20-200
SI/TIBC/TR 29/356/8 14-158/228-448/15-45
Urinalysis Yellow/Alb trace/Glu
negative/crystal amorph
3+/epitel transitional 0-1, epi
1+/leu 2-3 LPB/eri 1-2 LPB/Bact
(-)/Nitrite (-)/LEA (-)
 Blood Gas Analysis
18/11/21
Lab exam Normal Range

Artery

pH 7.524 7.35-7.45

pCO2 27.20 35-45

pO2 124.30 75-100

Sat O2 97.50 95-98

BE 1.30 -2.5-2.5

HCO3 22.60 21-25

Tot CO2 23.40 21-27

 Management Plan
No Problem Diagnostic Plan Management plan Target
Decreased consciousness CSF examination • VP Shunt
1. due to hydrocephalus and • OAT: Rifampicin 450 mg, Isoniazid
Increased GCS
meningitis TB GCS level monitoring 300 mg, Ethambutol 1000 mg
• Dexamethasone 1 x 20 mg IV
Electrolyte imbalance
2. hyponatremia (133), Electrolyte after • NaCl Caps 3 x 500 mg Normal natrium and
Hypokalaemia (3)
correction (7 days) • KCL Pulv 3 x 500 mg kalium level

Elevated transaminase • Adequate hydration (Asering 500

3. enzymes (220/110) due to Reevaluation AST/ALT ml/12 hour, fluid diet 6 x 200 ml Normal AST/ALT level
level (7 days) per NGT)
acute reaction
• Manage acute stressor
Reevaluation of CBC
Iron deficiency anemia
4. (10.1)
and iron profile after • - -
infection subsides

THANK YOU