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7/23/2019 peb pprom.pptx
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Case No. 65
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Name : Mrs. R
Age : 21 yrsAddress : Kuranji, Padang
MR No. : 93 04 21
Admission date : Desem!er 3rd, 201"
Patient’s ID
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• A 2# years o$d %atient admitted to t&e 'mergeny
Room o( Dr. M. Djami$ )enera$ *os%ita$ Padang on
Desem!er 3rd, 201" 11."" am, +it& &ie(
om%$ain since 6 hours ago fuidleakage rom the vagina
Anamnesis
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•
Preious$y %atient +as oming to R-P Dr. Mdami$ Padang (or $oo/at &is (ami$i, in R-P M.Dami$ t&ere are fuid leakage romthe vagina t&en %ation +ent to de$$iery room M.Djami$. n
de$iery room (ound !$ood %ressure +s &ig& 1#0130 Patient t&en
re(erred to M.Djami$ entra$ *os%ita$ +it& i $ine Mg-54 maintenanedose and urine at&eter atta&ed• Any om%$ain o( &eada&e, !$urred ision, or e%igastri %ain +as
a!sent•
Fluid leakage rom the vagina since 6 hours ago• Pain (rom +aist region +&i& re(erred to t&e groin +as a!sent• 6$oody s&o+ (rom t&e agina +as a!sent• 7&ere +as no massie agina$ !$eeding• Amenorr&ea sine 8 9 mont&s !e(ore
Present Illness!istor"
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irst date o( $ast menstrua$ %eriod 21"2013
'stimation date o( de$iery 2;22014
eta$ moement +as (e$t sine 8 4 mont&s !e(ore
No om%$ain o( nausea, omit, or agina$ !$eeding
during ear$y or $ate %regnany
Prenata$ are to mid+i(e in %rimary &ea$t& are eerymont& sine 2nd mont& %regnany. <ast ontro$ 2 +ee/s
ago. -&e said t&e %regnany +as +e$$ and t&ere +as no
&y%ertension. Menstrua$ &istory : menar&e at 13 years o$d, regu$ar
y$e in t&ree mont& !e(ore %regnany +it& t&e amount
o( 23 times %ad &angeday +it&out any menstrua$ %ain
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Previous Illness
!istor"• 7&ere +as no &istory o( &y%ertension, ardia, $ung,
$ier, or rena$ dia!etes me$$itus disease nor a$$ergy
• No &istory o( any ontagious, or %sy&o$ogia$disorder in t&e (ami$y
Famil" Illness!istor"
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• Marita$ -tatus : married in 2012• 5!stetris -tatus :
Pregnany De$iery A!ortion : 2 1 0
1. 2004, inom%$it a!ortion, uretage
2. Present•. *istory o( ami$y P$anning : •. mmuni=ation :
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Ph"sical #$amination)en on 6P *R RR 7 > urine
Moderate M 1#0100 92 20 3#? 300 at t&e time
Pate$$a re($e@ : N
6* 6B 6M A
14; ";43 19,C3 2C
'yes : onjuntia +as not anemi, s$era +as not iteriNe/ : EP "2 m*25, no en$argement o( t&yroid g$and
7&ora@ : *eart <ung F +it&in norma$ $imit
'@tremity : edema , %ate$$ar re($e@ n
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Obstetrics Records
Abdomen
•
ns%etion : en$arged aording to %reterm %regnany, mid$ine&y%er %igmentation , iatri@ • Pa$%ation :
– <1 : uterine (unda$ +as %a$%ated 4 (ingers !e$o+ %ro.
@y%&oideusA large sot nodular mass %as &al&a'le
– <2 : $argest resistane struture +as %a$%ated at $e(t
Numerous sma$$, irregu$ar struture +ere %a$%ated on t&erig&t
side – <3 : a &ard round mass +as %a$%ated not (i@ated – <4 : onergent
*: 2# mG '6B: 23;0 gr( uterine ontration :
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• Perussion : tym%ani• Ausu$tation : norma$ %erista$ti sound, *R : 1401"0
!%m
)enita$• ns%etion : u$a and uret&ra F +it&in norma$ $imit
•
agina$ e@amination• ∅ no di$atation
• Portio +as t&i/ 1," m, %osterior, medium
• '((aement 2030 H
• Amnioti sa +as di((iu$t to e@amine
• *ead %a$%ated, *
Pe$i sore 1
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n$et Pe$i :
• Promontory +as not rea&a!$e
•
nnominate $ine +as %a$%ated 1313• -arum !one : onae
• Pe$i side +a$$ : straig&t
• s&iadi s%ine : not %rotruded
• oygeus !one : moea!$e
• Ar o( %u!i : I90°
5ut$et Pe$i :
• nter tu!erous distane ou$d !e %assed t&roug& !y norma$adu$t (ist I 10," m
m%ression : no ontrated %e$i
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)*+
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)ltrasound
• Fetal alive singleton intrauterinehead &resentation
• Fetal movement %as good
• ,iometric - ,PD 65 mm #F/ 0122gr
AC 033 mm
F4 662 mm
• Placental im&lanted at anterior
cor&us gr IIIII
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Laboratory FindingParameter Result Normal Value Unit
Haemoglobin 9,4 12.00-14.00 g/dl
Leuo!te 129.000 ".#0-1#.90 10$/mm$
%ritro!te 4,& 4.00-".00 10#/'l
()rombo!te 10&.000 1"0.00-400.00 10$/mm$
Hematorit $& $&.00-4$.00 *
P( 9,2 10-1$,# se
+P(( $$,& 29,2-$9,4 se
Parameter R%UL( Normal Value Unit
Protein - g/dl
Urinalisa
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Parameter Result Normal Value Unit
LH "00 40 u/l
Potassium 3 $."-".1 mmol/L
odium 1$# 1$9-14" mmol/L
Random lood 5luose 2 200.00 mg/dL
(otal Protein ",9 #.0-&. g/dL
+lbumin $,# $."-".2 g/dL
5lobulin 2,$ 0.00-0.00 g/dL
56( 19 0.00-$1.00 u/L
5P( 14 0.00-$4.00 u/LUreum 9 1".00-40.00 mg/dL
7reatinine 1,$ 0.#0-1.20 mg/dL
8%R 1,1&4,29 0," g/dl
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Diagnosis :
• )2P0A1<0 %reterm %regnany 343C +ee/s
-eere Pree$am%sia on regimen Mg-54maintenane dose (rom ot&er intitution
PPR5M
• eta$ a$ie, sing$eton, intrauterine, &ead%resentation, *
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Management :
• ontro$$ing genera$ ondition, ita$ sign, ($uid !a$ane,
%ate$$ar re($e@, *R• n(ormed onsent
• Maintenane dose o( Mg-54 regimen• ')• a$$ Pree$am%sia 7eam : 5%&t&a$mo$ogy,
ardio$ogy, and agina$ De%artment• onsu$e %erinato$ogy
P$an : 7ermination
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6:)t)almolog! e:artment
• m%ression :
– Mi$d e$am%sia (undus +as (ound
– 7&era%y :
• Aording to 5!)yn De%t
7ardiolog! e:artment
• m%ression :
– -eere Pree$am%sia in )2P0A1<0 %reterm %regnany
3434 +ee/s
– Adie :
• Met&y$do%a 3@"00 mg
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nterne De%artment
• m%ression :
– -eere Pree$am%sia in )2P0A1<0 %reterm
%regnany 3434 +ee/s
– Adie :
• Met&y$do%a 3@"00 mg
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At 0C.30 %m :
• 7PP- +as %er(ormed• A ma$e !a!y +as !orn +it& 2300 g in +eig&t, 44 m in
$engt&, AP)AR sore 3C• P$aentas +as de$iered +it& mi$d tration on
um!i$ia$ ord, a %iee, 1C @ 1" @ 2," m in si=e, 4"0
g in +eig&t, um!i$ia$ ord $engt& +as "0 m,
%araentra$is insertion.• 6$ood $ose during surgery : 8 2"0
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Diagnosis :
• P1A1<1 %ost 7PP- on indiation o( -eere
Pree$am%sia PPR5M• Mot&er and !a!y +ere in are
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hank 7ou
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