Intensive Care Unit Report

Thursday, April 16th, 2015

Consultant:
dr. Djoni Taher, OBGYN (C)

April Team

Reporting

1 Patient

No

Patient

ER 2nd Floor

Latest Problems

1. Decrease of conciousness due

to severe septic
Mrs. Pudji Lestari, 55 y.o., P2
2. AKI dd/ Acute on CKD
MR 2152238
3. Leucocytosis (improved)
4. Hypoalbuminemia (2,9)
Day-3, P2 post curretage
5. Hypocalemia (2,15)
due to hyperplasia
6. Susp CAP
endometrial and extraction
IUD spiral loop
Collaboration with internist,
neurology, pulmonology,
anesthesiology

Latest condition (April 16th 2015)

Lab result (15/4/2014)

2nd Floor Pu
GCS : 10, Sat O2 99%
BP 143/106 mmHg (MAP : 114)
HR 88x/min, RR 24 x/min, T: 360C
CVP: 11

BGA: 7,402/41,5/109/25,3/26,6/1,1/98
E: 146/2,8/110
Ur/Cr: 39/1,1
Lactate: 0,6
CBC:
10/29/19.180/206.000//78,6/27/34,4

General st:
Eye: pale conjungtives -/- icteric -/-,
Cor : HS I, II regular, murmur (-)
gallop (-)
Pulmo : vesicular, crackles +/+,
wheezing -/Abd: ~ normal bowel sound
Gyn St :
Fundal height was not palpable,
I : v/u wnl, no vaginal bleeding
I : 2200 O :1600 B : +600 (D : 1,9
cc/kgBW/hr)
Th/
Meropenem 3x1gr IV, Levofloxacin
1x7,5 mg IV (postponed by
anaesthesiology), KCL 25 Meq/8

Monday, April 13th 2015

21.00

S: Decreased consciusness, not

adequate contact

O: BP: 100/70 mmHg, HR 114x/m

RR:22x/m Sat: 98% on RM 8l/m
Eye : not pale conjungtiva, sclera
not icteric
Pulmo : vesicular, no crackels, no
wheezing
Extremity: no edema

A:
Day-1, P2 post curretage due to
hyperplasia endometrial and
extraction IUD spiral loop
With severe sepsis and decreased
consciusness

P:
Plan to be moved to ICU

ICU was full observation in

delivery room by duty team

Tuesday, April 14th 2015

14.00

S: Decreased consciusness, not

adequate contact

O: BP: 100/78 mmHg, HR 114x/m

RR:24x/m Sat: 100% on RM 8l/m
Eye : not pale conjungtiva, sclera
not icteric
Pulmo : vesicular, no crackels, no
wheezing
Extremity: no edema

A:
Day-2, P2 post curretage due to
hyperplasia endometrial and
extraction IUD spiral loop
With severe sepsis and decreased
consciusness

P:
Plan to be moved to ICU

ICU is available (14.30)

BGA 7,39/29,8/78,6/18/5,4/95,8
RBG: 72
E: 144/3,5/105
OT/PT 59/30
Ur/Cr: 50/3,4
CBC:
12,6/37/36.820/287.000//80/27
,2/34
Lactate: 2,9

Vital Signs 15/4/201516/4/2015

160
140
120
100
80
60
40
20
0

Systole
Diastole
Pulse
RR

Temperature 15/4/2015-16/4/2015
Temperature
37.2
37
36.8
36.6
36.4
36.2
36

Temperature

Thank You