EMERGENCY ROOM REPORT

Monday, 30th July 2018

Chief On Duty :
Dr. Eric Tjahyadi
Dr. Abdul Bari

Resident on Duty:
Dr. Aprian Ilhami

Supervisor :
Dr. H. Iskandar Zulqarnain, SpOG(K)
 RECAPITULATION
Friday, July 20th 2018 until Thursday, July 26th 2018

OBSTETRICS Physiology patient 1 patients

Pathology patient 2 patients

GYNECOLOGY 2 patients

TOTAL PATIENT 5 patients

 RECAPITULATION
Friday, July 20th 2018 until Thursday, July 26th 2018
DATE OBSTETRIC GYNECOLOGY TOTAL
Friday, July 20th 2018 1 - 1

Monday, July 23th 2018 1 - 1

Tuesday, July 24th 2018

- - -

Wednesday, July 25th 2018

2 - 2

Thursday, July 26th 2018

1 - 1

Total 5 - 5
 RECAPITULATION
Friday, July 27th 2018

OBSTETRICS Physiology patient 0 patients

Pathology patient 3 patients

GYNECOLOGY patients

TOTAL PATIENT 3 patients

No. Identity Diagnosis ICD 10 Procedure ICD 9

Stabilization 1 – 3 hours
Inj MgSO4 according to
G2P1A0 38 weeks of gestational age in labor 1st protocols
Mrs. PUT
1 /29/UA
stage active phase + severe preeclampsia SLF O14.03 Antihypertension 650
Intrauterine Consult Internal Medicine,
Ophtalmology,
Plan Vaginal delivery

G2P1A0 38 weeks of gestational age not in labor + Obs.Vital sign,contraction,fetal heart rate
Mrs. MAR
2 /26/RA
cephalopelvic disproportion was suspected SLF O42.013 Plan for LSCS 669.7
cephalic presentation

Conservative
G2P1A0 32 weeks of gestational age not in labor
Obs.Vital sign,contraction,fetal heart rate
with PPROM 22 hours + prior cs 1x SLF cephalic
3 Mrs. RIS/31/UA
presentation
O42.013 Lung maturation 650
Antibiotics
 Identity Mrs. PUT /29/UA
27-7-2017 at 08.00 PM In Labor with high blood pressure
Chief complain

History 6 hours before admitted to the hospital patient complained about abdominal contraction often and harder (+),
bloody show (+), amniotic leakaged (-), hypertension before pregnancy (-), hypertension in prior pregnancy (-),
hypertension in this pregnancy (-), family had hypertension (+) her mother, blur vision (-), epigstrial pain (-),
nausea vomit (-), headache (-).
Patient admitted that her pregnancy was aterm and she can still felt the movement of the fetus

Marital status 1x 10 years

Reproduction status Menarche since 14 yo, regular cycle 28 days, for 5 days. LMP : 1/11/2017
Obstetric history 1. 2009, female, spontaneous delivery, Muhammadiyah hospital , 2300 g, healthy.
2. This pregnancy
Physical examination BP : 180/110 mmHg, P : 80 x/min, T : 36.5 C, RR : 20 x/min, Weight 56 kg, Height 155 cm
Edema pretibial (+)
Obstetrical Inspection & Palpation :
examination Fundal height was 3 fingers below proc. xyphoideus (30 cm),longitudinal lie, U 3/5, head, His (+) 3X/10’/35”,
IG 8 FHR: 140x/m, EFW : 3010 g
VT: Portio was soft, anterior , eff 75 %, Ø : 6 cm, head, H II, amniotic membrane (+) and denominator tranverse
sagitalis suture

US ER - Single life fetus cephalic presentation

- Fetal Biometry: BPD 9,03 cm AC 30.21 cm
HC 29.93 cm FL 7.2 cm EFW : 2780 g
- Placenta at anterior corpus of the uterine
- Amniotic fluid was normal, SP 2.8 cm
C/ 38 weeks gestational age SLF cephalic presentation
 Identity Mrs. PUT /29/UA

Laboratory Hb: 13.0 g/dl, wbc 17.000/ mm3, trombosit 202.000/mm3, Ht 40 %, Proteinuria +3, LDH 531 U/L, Uric acid
Examination 5.03 mg/dL
Diagnosis G2P1A0 38 weeks of gestational age in labor 1st stage active phase + severe preeclampsia SLF cephalic
presentation
Therapy • Stabilization 1-3 hours
• IVFD RL gtt xx/m
• Catheter
• MgSO4  protocol IM
• Nifedipine 10 mg/8 hours PO
• Assessment of Internal Department, Opthalmology Department Evaluation with gestosis task
• P/ Abdominal termination
Assessment of A/ Gestational hypertension
Internal Department P/ Metildopa 500 mg/8 hours PO

Assessment of A/ There were no ophthalmologic disorder in both eyes

Opthalmology Dept P/ - Hypertensive regulation in obgyn protocol
- Consult again if there’s suddenly decreasing visus
Diagnosis
12.50 pm G2P1A0 38 weeks of gestational age in labor 2nd stage + severe preeclampsia SLF cephalic presentation
Ø fully dilated
IG : 4
Labor Report 13.00 PM female life baby was born, BW 2750g, BL 48 cm, A/S: 8/9 FTAGA.
July 27th 2018 13.05 PM Placenta delivered completely, PW: 450 gram, UCL 48cm, diameter 17 x 18 cm
Dx: P2A0 post spontaneous delivery + severe preecclampsia
29/07/2018 Patient was discharged
 IDENTITY Mrs. MAR /26/RA
27-07-2018 at 09.05 AM Aterm pregnancy with cephalopelvic disproportion was suspected
Chief complain
History Patient referred from OBGYN with G2P0A1 38 weeks of gestational age not in labor with cephalo
pelvic disprorportion was suspected. abdominal contraction (-), bloody show (-), amniotic leakage
(-).
Patient admitted that her pregnancy was aterm and she can still felt the movement of the fetus
Marital status 1x, 3 year
Reproduction Menarche since 13 yo, regular cycle 28 days, for 5 days, LMP : 02 Nov 2017
status
Obstetric history 1. 2017 abortus, 8 weeks, curettage, OBGYN ( C )
2. 2018 This pregnancy
Physical BP : 110/70 mmHg, P : 86 x/min, T : 36.7 C, RR : 20 x/min, Weight : 54 kg, Height : 140 cm
examination
Obstetrical Palpation : Uterine fundal height was in 3 fingers below proc. xyphoideus (38 cm), longitudinal
examination lie, back at left side, head, U 5/5, His (-), FHR: 143x/m, EFW : 3875 g Osborn test (+)
VT: Portio was soft, medial, eff 0 %, Ø 0 cm, head, HI, amniotic membrane and denominator cant
be assessed
US ER - Single life fetus cephalic presentation
- Fetal Biometry: BPD 9.36 cm AC 35.41 cm EFW : 3796 g
HC 33.78 cm FL 7.18 cm
- Placenta at posterior corpus of the uterine
- Amniotic fluid sufficient, SDP = 4.78 cm
C/ 38 weeks gestational age SLF cephalic presentation
Laboratory Hb: 12.0 g/dl, WBC 7.600/mm3, Platelet 265.000/mm3, Ht 32%
examination
 IDENTITY Mrs. MAR /26/RA
Diagnosis G2P1A0 38 weeks of gestational age not in labor + cephalopelvic disproportion was suspected SLF
cephalic presentation
Therapy • Observed vital sign, contractions, FHR
• IVFD RL xx drops/min
• P/ LSCS

Operative report At 19.20 PM male life baby was born with LSCS, BW 3500 g, BL 50 cm A/S 8/9 FTAGA.
At 19.25 PM placenta was delivered completely, PW 550 g, UCL 49 cm, diameter 20 x 19 cm

Follow up S/ Post LSCS o.i cephalopelvic disproportion

28/07/2018 0/ sense : cm
BP 120/80 mmhg
Pulse : 80 x/m
RR: 20x/m
T: 36.9
Palpation :
Uterine fundal height 2 fingers below umbilicus,, contraction (+), bleeding(-) ,Lochia (+) rubra
A/ P2A0 Post LSCS o.i cephalopelvic disproportion
P/ Observation vital sign,contraction ,bleeding
Asi on demand
Vulva Hygiene
Inj Ceftriaxone 1 gr/12 hours
Inj Ketorolac 30 mg / 8 hours
Inj Tranexamic Acid 500 mg /8 hours

Follow up Patient was stable in ward

29/07/2018
 IDENTITY Mrs. RIS/31/UA
27-07-2018 at 07.10 AM Preterm pregnancy with amniotic leakage
Chief complain
History 9 hours before admission, patient complained amniotic leakage, amount 2x changing wet pad, clear,
smelly (-), abdominal contraction (+), bloody show (-). History of : trauma (-), leucorrhea (+), post
coital (-), toothache (-), skin infection (-), traditional herbal drink (-), traditional massage in
abdominal (-), fever(-).
Patient admitted that her pregnancy was preterm and she can still felt the movement of the fetus
Marital status 1x, 5 year
Reproduction status Menarche since 12 yo, regular cycle 28 days, for 5 days, LMP : 15 Dec 2017
Obstetric history 1. 2014, Female, 3600g, LSCS o.i fetal distress, healthy
2. This pregnancy
Physical BP : 120/80 mmHg, P : 80 x/min, T : 36.8 C, RR : 20 x/min, Weight : 82 kg, Height : 160 cm
examination
Obstetrical Palpation : Uterine fundal height was in 3 fingers above umbilicus (24 cm), longitudinal lie, back at
examination right side, head, U 5/5, FHR: 150x/m, EFW : 1705 g
Inspeculo : Portio livide, closed OUE, fluor (-), fluxus (+) amniotic fluid but didn’t active, Lacmus test
(+) red  blue,E/L/P (-)
VT: Portio was soft, posterior, eff 0%, Ø closed OUE, head, HI-II, amniotic leakage, clear, smelly(-
),and denominator can’t be assessed
US fetomaternal - Single life fetus cephalic presentation
- Fetal Biometry: BPD 7.61 cm AC 24.21 cm EFW : 1418 g
HC 27.33 cm FL 5.38 cm
- Placenta at anterior corpus of the uterine
- Amniotic fluid sufficient, SDP = 2.14 cm
C/ 32 weeks gestational age SLF cephalic presentation + susp IUGR
Laboratory Hb: 12.5 g/dl, WBC 12.300/ mm3, Platelet 273.000/mm3, Ht 35%, CRP (+) , LEA (-)
examination
 IDENTITY Mrs. RIS/31/UA
Diagnosis G2P1A0 32 weeks of gestational age not in labor with PPROM 5 hours + prior cs 1x SLF cephalic
presentation + IUGR was suspected

Therapy • Conservative
• Observed vital sign, contractions, FHR
• IVFD RL xx drops/min
• Ampicilline inj 1gr/8 hours IV
• Lung maturation with dexamethasone 12 mg / 24 hours
• Nipedifine 10 mg / 6 hours
Follow up S/Preterm pregnancy with amniotic leakage
28/07/2018 0/ sense : cm
BP 120/80 mmhg
Pulse : 80 x/m
RR: 20 x/m
T: 36.9
A/ G2P1A0 32 weeks of gestational age not in labor with PPROM 23 hours + prior cs 1x SLF cephalic presentation
+ IUGR was suspected
P/
• Conservative
• Observed vital sign, contractions, FHR
• IVFD RL xx drops/min
• Ampicilline inj 1gr/8 hours IV
• Lung maturation with dexamethasone 12 mg / 24 hours
• Nipedifine 10 mg / 6 hours

Follow up
29/07/2018 Patient was stable inward