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Residents:
dr. Rizky Fachriza Hrp
dr. Paul A Khoman
PATIENT 1
FOLLOW UP
Wednesday, 27th January 2016
Chief Complaint: Pain on the abdominal wound
Present State
Consc
: Alert
Anemic
: (-)
Icteric
: (-)
: (-)
BP
: 140/85 mmHg
HR
: 89 x/i
Cyanotic
RR
: 19 x/i
Dispnoe
Temp : 36,8oC
Oedem
: (-)
: (-)
Generalized state
Head
Eye
Nose
Abdomen
Extremities
Localised state
Abdomen
Fundal Height
Operative Wound
Vaginal Bleeding
Micturition
Defecation
Amlodipine 1x10 mg
Nifedipine 1 x 10 mg
Plan :
Continue therapy
Plan
:
Perform routine blood count, HELLP panel, LFT, RFT, Bilirubin total,
Bilirubin direct, Fibrinogen, D-Dimer, ALP, LDH, Albumin
Therapy
:
Plan
:
Perform RFT
Perform kidney and urinary tract ultrasonography when patients
condition is stable
Gastroenterohepatology
Answer
Diagnosis
(GEH)
Division
Consult
Therapy
:
Plan
:
Perform LFT
Perform abdominal ultrasonography when patients condition is
stable
26/01/16
(06:54)
Hb
Ht
Leu
PLT
26/01/16
(15:00)
: 14,2 gr/dL
: 38,5 %
: 7690 /mm3
: 31.000 /mm3
PT
: 12,5 (C 13,9 s)
APTT: 33,2 (C 33,9 s)
TT
: 22,3 (C 17,5 s)
INR : 0,93
Fibrinogen: 299 mg/dL
D-Dimer : 2200 ng/mL
Ureum
: 67,47
mg/dL
Creatinine: 1,96 mg/dL
Albumin
Na
K
Cl
mEq/L
: 3,0 g/dL
: 135 mEq/L
: 3,5 mEq/L
: 102
Hb
Ht
Leu
PLT
: 11,9 gr/dL
: 32,2
: 13.710 /mm3
: 55.000 /mm3
27/01/16
Hb
Ht
Leu
PLT
: 8,4 gr/dL
: 22,8 %
: 23.610 /mm3
: 101.000 /mm3
FOLLOW UP
Thursday, 28th January 2016
Chief Complaint: Pain on the abdominal wound
Present State
Consc
: Alert
Anemic
: (-)
Icteric
: (-)
: (-)
BP
: 140/90 mmHg
HR
: 85 x/i
Cyanotic
RR
: 17 x/i
Dispnoe
Temp : 36,5oC
Oedem
: (-)
: (-)
Generalized state
Head
Eye
Nose
Abdomen
Extremities
Localised state
Abdomen
Fundal Height
Operative Wound
Vaginal Bleeding
Micturition
Defecation
Diagnosis
Therapy
:
IVFD RL 20 drops/minute
Amlodipine 1x10 mg
Plan
:
Continue therapy
ultrasonography
(Nephrology
&
FOLLOW UP
Friday, 29th January 2016
Chief Complaint: Pain on the abdominal wound
Present State
Consc
: Alert
Anemic
: (+)
Icteric
: (+)
BP
: 150/90 mmHg
HR
: 90 x/i
Cyanotic
RR
: 18 x/i
Dispnoe
Temp : 36,6oC
Oedem
: (-)
: (-)
: (-)
Generalized state
Head
Eye
Nose
Abdomen
Extremities
Localised state
Abdomen
Fundal Height
Operative Wound
Vaginal Bleeding
Micturition
Defecation
Diagnosis
Therapy
:
IVFD RL 20 drops/minute
Amlodipine 1x10 mg
Plan
:
Liver
&
Abdomen
ultrasonography
(Nephrology
&
Gastroenterohepatology division)
Complete blood count, HST, BT, RFT, LFT, D-Dimer, Fibrinogen, LDH
FOLLOW UP
Saturday, 30th January 2016
Chief Complaint: Pain on the abdominal wound
Present State
Consc
: Alert
Anemic
: (+)
Icteric
: (+)
BP
: 145/90 mmHg
HR
: 82 x/i
Cyanotic
RR
: 20 x/i
Dispnoe
Temp : 36,5oC
Oedem
: (-)
: (-)
: (-)
Generalized state
Head
Eye
Nose
Abdomen
Extremities
Localised state
Abdomen
Fundal Height
Operative Wound
Vaginal Bleeding
Micturition
Defecation
Diagnosis
Therapy
:
IVFD RL 20 drops/minute
Amlodipine 1x10 mg
Plan
:
Continue therapy
PRC Transfussion: (10-6,6) x 50 x 3 / 175cc = 2,91 3 PRC
Consult internal division for transfusion tolerance
27/01/16
29/01/16
Hb
Ht
Leu
PLT
Hb : 6,6 gr/dL
Ht : 22,8 %
Leu : 15.540 /mm3
PLT : 139.000
/mm3
: 8,4 gr/dL
: 22,8 %
: 23.610 /mm3
: 101.000 /mm3
BT: 3
PT
: 10 (C:
14,3)
APTT: 24
(C:
34,5)
TT
: 25,6 (C:
17,5)
SGOT/SGPT :
62/53
LDH
:
1002
BUN
Ureum
Creatinine
: 78
: 167
: 3,3
26/01/16
(06:54)
Hb
Ht
Leu
PLT
26/01/16
(15:00)
: 14,2 gr/dL
: 38,5 %
: 7690 /mm3
: 31.000 /mm3
PT
: 12,5 (C 13,9 s)
APTT: 33,2 (C 33,9 s)
TT
: 22,3 (C 17,5 s)
INR : 0,93
Fibrinogen: 299 mg/dL
D-Dimer : 2200 ng/mL
Ureum
: 67,47
mg/dL
Creatinine: 1,96 mg/dL
Albumin
Na
K
Cl
mEq/L
: 3,0 g/dL
: 135 mEq/L
: 3,5 mEq/L
: 102
Hb
Ht
Leu
PLT
: 11,9 gr/dL
: 32,2
: 13.710 /mm3
: 55.000 /mm3
FOLLOW UP
Sunday, 31st January 2016
Chief Complaint:
Present State
Consc
: Alert
Anemic
: (+)
Icteric
: (+)
BP
: 150/80 mmHg
HR
: 81 x/i
Cyanotic
RR
: 20 x/i
Dispnoe
Temp : 36,3oC
Oedem
: (-)
: (-)
: (-)
Generalized state
Head
Eye
Nose
Abdomen
Extremities
Localised state
Abdomen
Fundal Height
Operative Wound
Vaginal Bleeding
Micturition
Defecation
Diagnosis
Therapy
:
IVFD RL 20 drops/minute
Amlodipine 1x10 mg
Plan
:
Complete blood count 6 hours post transfusion
FOLLOW UP
Monday, 1st February 2016
Chief Complaint: Pain on the abdominal wound
Present State
Consc
: Alert
Anemic
: (-)
Icteric
: (-)
: (-)
BP
: 140/90 mmHg
HR
: 85 x/i
Cyanotic
RR
: 17 x/i
Dispnoe
Temp : 36,5oC
Oedem
: (-)
: (-)
Generalized state
Head
Eye
Nose
Abdomen
Extremities
Localised state
Abdomen
Fundal Height
Operative Wound
Vaginal Bleeding
Micturition
Defecation
Diagnosis
Therapy
:
IVFD RL 20 drops/minute
Amlodipine 1x10 mg
Plan
:
a
THANK YOU