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56
Identity
Name : Mrs. A
Age : 23 years old
MR No.: 97 81 36
Date : Mai 09th, 2017
Chief Complaint:
A 23 years old patient was admitted
to the Emergency Room of Dr. M.
Djamil Central General Hospital on
July 27th, 2016 at 17:00 pm refered
by Private hospital with diagnosed:
loss of Consciousness ec Eclampsia
ante partum at G1P0A0L0 term
parturient stage I active phase +
HELLP sindrome
Present Illness History
Patient was seizures two time at midwife clinic, patient refered to
Pvite Hospital West Pasaman, at West Pasaman Privete Hospital
Patient was seizure once, on examination the blood preasure 180/120,
patient got regimen MgSO4 initial dose, and maintenance dose,
Catheter dan Inj Dexametason 2 amp and patient was refered to M
Djamil Hospital. The patient came to M Djamil hospital with MgS04
regimen and catheter.
Headeche (-), Blur vision (-), epigastric pain (-)
Feeling of pain from waist to region which referred to the groin 10
hours ago
Bloody show from the vagina was abcent 10 hours ago
fluid leakage from the vagina (+) since 1 hous ago
There was no massive vaginal bleeding
Amenorrhea since 9 months ago
First date of last menstrual : Forget
Estimation date of delivery : difficult to examined
Fetal movement was felt since 4
months ago
No complain of nausea, vomiting, or
vaginal bleeding neither during early
nor late pregnancy
Prenatal care to midwife three times on
2,3, and 5 month of pregnancy.
Menstrual history : menarche at 13
years old, iregular cycle, 5-7 days each
cycle with the amount of 2-3 times pad
change/day without any menstrual pain.
Previous Illness History
There was no previous history of heart, lung, liver, kidney
disease, DM, hypertension and allergy
Abdomen
Inspection : Abdomen seems enlarged in accordance with term
pregnancy, mid line hyperpigmentation (+), striae
gravidarum (+), sicatricks (-)
Palpation :
L1 Uterine fundal was palpable 3 fingers below proc.xiphoideus,
a large nodular mass was palpable
L2 hard and resistance structure was palpated on the left side.
Numerous small, irregular structure were palpated on the right
side
L3 hard mass was palpable, fixed
L4 Convergen
UFH: 34cm cm; EBW: 3410 gr ; Uterine contraction : 2-3X/35/M
Percussion : Tympani
Auscultation : Peristaltic sound was normal, Fetal heart sound: 103-
112
Obstetric Record
Genitalia
Inspection : v/u within normal limits, no vaginal
bleeding
Internal examination :
: 5-6cm
Amniotic sac (-), Greenish residue
Head presentation, anterior left occiput, H II-III
USG
Fetal alive, singleton,intra uterine, head
presentation.
Fetal movement (+)
Biometrics :
BPD : 94,1 mm
AC : 265 mm
FL : 70,0 mm
EFW: 1454 gr
Placenta was implanted in posterior corpus grade II
Impession : 3-34 weeks term pregnancy
Fetal alive, head presentation
PARAMETER Laboratory findings Normal Value
Hemoglobin 13,0 gr/dl 9.5-15
Leukosit 11.760/mm3 5.000 16.000
Hematokrit 38 % 37 43
Trombosit 50.000 /mm3 150.000 400.000
APTT 51,1 detik 29,2 39,4
PT 13,4 detik 10 13,6
Ureum darah 51 mg/dl 16,6 48,5
Creatinin darah 0,8 mg/dl 0,6 1,2
LDH 1735 u/l 0 480
SGOT 47 u/l 0 31
SGPT 46 u/l 0 34
Total bilirubin 0,8 mg/dL 0,1 1,2