EMERGENCY ROOM REPORT

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Friday, December 28 2018

Resident on duty:
Dr. Aria Indrabrata
Dr. Ceza Kautsar- Dr. Dian Aviani

Chief on duty :
Dr. Ibnu Sina

Supervisor :
Dr. H. Iskandar Zulqarnain, OBGYN(C)
 RECAPITULATION
Friday, December 28th 2018

Obstetrics Physiology Patient 0 Patient

Pathology Patient 2 Patient

Gynecology 3 Patients

Total Patient 5 Patients

 RECAPITULATION
Friday, December 21st – Thursday, 27th December 2018
DATE OBSTETRICS GYNECOLOGY TOTAL

Friday, December 21st 2018 1 1 2

Monday December 24th 2018 0 0 0

Tuesday, December 25th 2018 0 0 0

Wednesday, December 26th 2018 1 1 2

Thursday, December 27th 2018 0 1 1

Total 2 3
 RECAPITULATION
Friday, December 21st – Thursday, 27th December 2018

Procedural AMOUNT %

Spontaneous Delivery 1 20

Brandt Andrew 1 20

Bed Rest 2 40

General Condition Improvement 1 20

TOTAL 5 100
 RECAPITULATION
Friday, December 21st – Thursday, 27th December 2018
Date Diagnose Amount % Procedure Amount %
Incarserated Placenta 1 20 Brandt andrew manouvre 1 20
st
Friday, Desember 21 2018 1 Bed Rest + Medicinalis 1
Threatened Abortion 20 20

Mon, Desember 24th 2018 - - - -

Tue, Desember 25th 2018 - - - -

Severe Preeclampsia 1 20 Vaginal Delivery 1 20

Wed, Desember 26th 2018
Ovarium cancer inadequate staging 1 20 General condition Improvement 1 20

Thurs, Desember 27th 2018 Threatened Abortion 1 20 Bed Rest + Medicinalis 1 20

Total 5 100 5 100

 EMERGENCY ROOM REPORT
OBSTETRICS
NUM IDENTITY DIAGNOSIS ICD 10 PROCEDURE ICD 9 Condition PHYSICIAN

P3A2post spontaneus delivery

(2 hours outside) with early O73.0 669.70 Discharge EZA
Mrs. THE / 38 yo/ post partum hemorrhage ec D64.9 Brandt- Andrew Manuever 66.32 GIS
1.
1097078/ UA incarserated placenta+ Tranfusion PRC RS
moderate anemia
Mrs DES/ 21 yo/ G1P0A0 38 weeks gestational Z34.93 Stabilization E936 Discharge DAV
840623/ RA age inlabor 1st stage laten O14.13 Anticonvulsant 401.9 IBE
phase with severe Antihypertensive 650 IZ
2.
preeclampsia Vaginal Delivery
SLF cephalic presentation
 EMERGENCY ROOM REPORT
GYNECOLOGY
NUM IDENTITY DIAGNOSIS ICD 10 PROCEDURE ICD 9 Condition PHYSICIAN

G3P0A2 7 weeks gestational age Z34.01 Bed Rest 99.2 Discharge GIS
1. Mrs. YUL / 32 yo/ with threatened abortion O20.0 Medicinalis EZA
1096952/ UA Single Life Fetus Intrauterine NS

General condition 99.07 DAV

Mrs. IDA / 40 yo / Ovarium Cancer Inadequate C56.90 improvement 87.44 Stable in IBE
2 1080207 / RA Staging + Obs Dyspneu + E88.0 Albumin transfusion ward AT
Hypoalbuminemia Chest x ray
Ass Internal Dept
G3P0A2 4 weeks gestational age Bedrest 99.07 Stable in DAV
Mrs. DEW / 26 yo / with threatened abortion + Z34.01 Medicinalis ward IBE
3 1093121/ UA Antiphospolipid Syndrome O20.0 Ass Internal Dept IS
Intrauterine D68.61
 OBSTETRICS
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FRIDAY DEC 21 2018
 Mrs. THE / 38 yo/ 1097078/ UA
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December 21 2018 at 08.30 AM
Chief complaint Post spontaneous delivery outside with vaginal bleeding
History ± 2 hours before admitted to hospital, patient was giving birth at midwife, male live neonatus, crying, but not
followed by delivery of placentae, active vaginal bleeding (+). Patient then referred to RSMH

Marital status Married 1 time, 8 years

Reproduction status Menarche since 14 yo, reguler cycle 28 days, 7 days, LMP forget
Obstetric history 1. 2004, gemelli a)male, 2400 gr b)male 2000 gr. Aterm, spontaneus delivery, midwife. Both alive
2. 2007. Abortus, 12 weeks of gestational age. Curretage at Aliyah Clinic
3. 2011. Abortus, 12 weeks of gestational age. Curretage at Charitas Hospita;
4. 2014. Female 4200 gr, aterm, spontaneous delivery, midwife, Aliyah Clinic, Alive
5. 2018 Male 4000gr, aterm, spontaneous delivery, midwife, Aliyah Clinic, Alive

Physical Examination BP: 90/60mmHg, HR: 108x/m, temp: 36C, RR: 24x/m, Weight: 54kg, Height: 152cm
Obstetrical examination Palpation: fundal height at umbilical, contraction (+), mass (-), free fluid sign (-), pain (-), there was umbilical cord
with clamp in front of vagina.
Speculum examination: OUE was opened, there was umbilical cord out of OUE, fluor (-), fluxus (+) blood was
active, E/L/P (-)
VT: Soft portio, OUE was opened, placenta was palpable in OUE.
Lab examination Hb: 7.2, WBC: 22.900, PLT: 330.000, HT: 17,
Diagnosis P3A0 post spontaneus delivery (3 hours outside) with early post partum hemorrhage ec retained placenta +
moderate anemia
Planning Obs. Vital sign, contraction, bleeding
Rehydration 2 line with IVFD RL XL drops / minutes ( 1 L ) and IVFD RL + oxytocin 20 IU gtt XXX/m
O2 3L / m (Canule)
Ceftriaxone 1 gr / 12 hours IV)
Brandt- Andrew Manuevre
PRC tranfussion

Operative Report Performed Brandt- Andrew Manuevre

December 21st 2018 Placenta was delivery completely PW 550 g, 18 x 19 cm,
At 09.00 D/ P3A2 post Brandt- Andrew Manuevre oi incarcerated placentae
Follow Up Patient was discharge
 GYNECOLOGY
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FRIDAY, DEC 21 2018
 Mrs. YUL / 32 yo/ 1096952/ UA
st
December 21 2018 at 12.30 AM
Chief complaint Early pregnancy with vaginal bleeding
History 1 day before admission, patient complain for vaginal bleeding(+), abdominal contraction (-). History of trauma (-),
history of leucorrhea (-), history of post coital (-), toothache (-), skin infection (-), traditional herbal drink (-),
traditional massage in abdominal (-), fever(-).
Patient admitted that her pregnancy was early and she was pregnant for 2 months

Marital status Married 1 time, 3 years

Reproduction status Menarche since 14 yo, reguler cycle 28 days, 7 days, LMP 29-10-2018
Obstetric history 1. March 2018. Abortus, 12 weeks of gestational age. Curretage at Hermina Hospital

Physical Examination BP: 120/70mmHg, HR: 82x/m, temp: 36C, RR: 20x/m, Weight: 50kg, Height: 160cm
Obstetrical examination Palpation : Uterine fundal not palpable, ballottement externa (-), stiffness (-), free fluid sign(-), mass (-),
contraction (-).
Inspeculo : portio livide, OUE closed, Fluor (-), fluxus (-), E/L/P (-)
VT: not performed
Lab examination Hb: 11.2, WBC: 8.900, PLT: 330.000, HT: 37
US ER -Single life fetus intrauterine
-CRL 1.89 cm
-Fetal pole (+)
-Fetal echo (+)
-C/ 8 weeks gestational age SLF intrauterine
Diagnosis G3P0A2 7 weeks gestational age with threatened abortion Single Life Fetus Intrauterine

Planning Obs. Vital sign

Bedrest
IVFD RL + transamin 500mg xx drops/m
Cygest 400 mcg/12h PV
 OBSTETRICS
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WEDNESDAY DEC 26 2018
 Identity Mrs. DES / 21 yo/ 1068108/ UA/ IZ
Chief complain Aterm pregnancy Inlabor with high blood pressure
History History of abdominal contraction (+), bloody show (+), amniotic leakage (-) History of hypertension this pregnancy (-), history of
26-12-2018 at 08.55 AM hypertension before pregnancy (-), history hypertension on family (-), headache (-), vomit and nausea (-), blurry vision (-), epigastric
pain (-), Patient admit that her pregnancy is aterm and still feel the movement of the fetus.

Marital status 1x, 1 years

Reproduction status Menarche since 14 y.o, regular, LMP:4-04-2018

Obstetric history 1. This pregnancy
Physical examination BP : 160/110 mmHg, P : 92x/min, T : 36.5 C, RR : 20 x/min BW: 55 kg, BL: 140 cm BMI: 28.06 (
Obstetrical examination Palpation : Fundal height was 3 cm below proc. xyphoideus (31 cm), longitudinal lie, left back, head, 4/5, uterine contraction 2x/
10’/30”, FHR : 140x/m, EFW: 2945 grams
VT: portio soft,medial, eff 100%, closed, 2 cm ,amniotic membrane (+), denominator transversal sagittal suture
Dipstick proteinuria ++
Pretibial Edema (+/+)
Gestosis index : 6
 Laboratory Hb: 8.6 g/dl WBC: 13.400 PLT: 181.000 Ht: 28% Total bilirubin 0.50 SGOT 27 SGPT 10 LDH 355 Uric acid 5.7 Ca 9.0 Mg 1.80 Na 141 K
4.0
Urine protein : ++
US (ER) • Single life fetus chepalic presentation
• BPD :8.62 cm HC: 32.56. cm AC: 32.37 cm FL: 7.03 cm EFW: 2894 grams
• Placenta at anterior corpus
• Amnionic volume sufficient, SDP : 2.33 cm
38 weeks gestastional age cephalic presentation
Diagnosis G1P0A0 38 weeks gestational age inlabor 1 st stage laten phase with severe preeclampsia
SLF cephalic presentation + moderate anemia
Opthalmology Assessment No abnormality was found

Internal Dept A: Hypertension in pregnancy

Assessment P: Diet Salt Intake
Methyldopa 250 mg/ 8 hr

Therapy • Stabilization 1-3 hours

• Observed vital sign, FHR,
• IVFD RL xx dpm
• Laboratory examination
• MgSO 4 40% ~ protocol
• Urine Catheterization, fluid balance monitoring
• Consult to Internal Department, Ophtalmology Department
• Nifedipine 10mg/ 8 hours per oral
• Evaluation ~ Gestosis task
• P/ Vaginal Delivery
 Follow up post BP : 140/90 mmHg, P : 92x/min, T : 36.5 C, RR : 20 x/min
stabilization Palpation : Fundal height was 3 cm below proc. xyphoideus (31 cm), longitudinal lie, left back, head, 4/5, uterine contraction 2x/
11.55 10’/30”, FHR : 140x/m, EFW: 2945 grams
VT: portio soft,medial, eff 100%, 3 cm ,amniotic membrane (+), denominator transversal sagittal suture
GI : 4 Dipstick proteinuria ++
G1P0A0 38 weeks Pretibial Edema (+/+)
gestational age inlabor 1 st Gestosis index : 4
stage latent phase with •Observation vital sign, contraction, FHR
•MgSO 4 40% ~ protocol
severe preeclampsia
•IVFD RL xx dpm
SLF cephalic presentation + •Urine Catheterization, fluid balance monitoring
moderate anemia •Nifedipine 10mg/ 8 hours per oral
•Oxytocin drops 5IU ( definitive drops)
•P/ Vaginal Delivery

14.00 BP : 140/90 mmHg, P : 88x/min, T : 36.7 C, RR : 20 x/min

Palpation : Fundal height was 3 cm below proc. xyphoideus (31 cm), longitudinal lie, left back, head, 3/5, uterine contraction 3x/
GI 4 10’/30”, FHR : 151x/m, EFW: 2945 grams
VT: portio soft,anterior, eff 100%, 5 cm ,amniotic membrane (+), denominator transversal sagittal suture
G1P0A0 38 weeks Dipstick proteinuria ++
gestational age inlabor 1 st Pretibial Edema (+/+)
stage active phase with Gestosis index : 4
•Observation vital sign, contraction, FHR
severe preeclampsia
•MgSO 4 40% ~ protocol
SLF cephalic presentation + •IVFD RL xx dpm
moderate anemia •Urine Catheterization, fluid balance monitoring
•Nifedipine 10mg/ 8 hours per oral
•Oxytocin drops 5IU ( definitive drops)
•P/ Vaginal Delivery

17.30 Female life baby was born, BW: 2700 g, BL: 47 cm, A/S: 8/9 FTAGA
 GYNECOLOGY
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WEDNESDAY DEC 26 2018
 Identity Mrs. IDA / 40 yo/ RA/ AT
Chief complain Abdominal enlargment and shorthness of breath

History Patient complained abdominal enlargement Since 3 months ago, pain (-). Since 1 months ago she complained of shortness of
26-12-2018 at 09.50 AM breath. history of vaginal bleeding (-) history of loss of appetite (+) decreased of body weight (+), difficulties in mixturition and
defecation (-), patient has been operated April 2018 and has unilateral salphingooophorectomy with PA exam no. path.143.4.18
Clear cell Renal Cell Carcinoma. Patient was reffered to Gynecology Oncology Clinic RSMH and plan to Surgical Staging after
Chemoterapy 3 course. Patient was hospitalized 4/11/18 and had chemotherapy 1 course (docetaxel-carboplatin) 9/11/18, not
continue the 2 nd course.

Marital status 1x, 23 years

Reproduction status Menarche since 13 y. o, regular, LMP : 8/2018
Obstetric history P4A0

Physical examination BP : 130/80 mmHg, P : 118x/min, T : 36.6 C, RR : 40 x/min BW: 55 kg BL: 155 cm

Gynecological examination Palpation: abdominal convex, tense, asymmetrical, uterine fundal not palpable, mass (+) was palpable with unclear borders,
upper border 1 finger below xiphoideus proc, lower border: symphysis, upper to lower border 48 cm, left border: posterior
axillary line, right border : posterior axillary line, Tenderness (-), free fluid sign (+), abdominal circumference : 103 cm
Inspeculo, VT, RT: not performed ( patient refused)

Laboratory Hb: 10.2 g/dl WBC: 7.900 PLT: 446.000 Ht: 33% Alb: 2.4 Na/K/Ca: 142/4.3/8.0 Ur/Cr: 17/0.67

US confirmation (NS) Solid mass in abdomen 36x39 cm

6/11/18 Hidronefrosis dextra
A: new growth of mass
Abdominal CT scan Septal cystic mass in pelvic
16/11/18 A: mucinous ovarian mass dd/ pseudomyxoma peritoneal ascites loculare
 Diagnosis Ovarium Cancer Inadequate Staging + Obs Dyspneu + Hypoalbuminemia

Internal Dept Subdiafragm process cb intraabdominal mass

Dd/ Lungs metastase

Therapy Observation vital sign

O2 10 L/m
IVFD RL gtt XX/ m
Laboratory examination
Pronalgest suppositoria
Albumin Infusion
CaCO3 500 mg/ 24 hr
Internal Dept Assessment
Chest X-Ray
 GYNECOLOGY
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THURSDAY DEC 27 2018
 Mrs. DEW / 26 yo/ 1093121/ UA/IS
December 27th 2018 at 10.30 AM
Chief complaint Early pregnancy with vaginal bleeding
History 1 day before admission, patient complain for vaginal bleeding(+), abdominal contraction (-). History of trauma (-), history of
leucorrhea (-), history of post coital (-), toothache (-), skin infection (-), traditional herbal drink (-), traditional massage in
abdominal (-), fever(-).
Patient admitted that her pregnancy was early and she was pregnant for 1 months

Marital status Married 1 time, 3 years

Reproduction status Menarche since 14 yo, reguler cycle 28 days, 7 days, LMP : forgot
Obstetric history 1. August 2017. Abortus, 12 weeks of gestational age. Curretage at M. Rabbain Hospital
2. December 2017. Abortus, 10 weeks of gestational age. Curretage at Charitas Hospital
3. Current Pregnancy
Past Illness History Patient was diagnosed at RS Cikini with APS since January 2017
Myfortic 2x1 was stopped
Seralto 1x1 was stopped
Thromboaspilet 1x1
Methyl Prednisolon 1x 4mg
Physical Examination BP: 110/70mmHg, HR: 82x/m, temp: 36C, RR: 20x/m, Weight: 49kg, Height: 158cm
Obstetrical examination Palpation : Uterine fundal not palpable, ballottement externa (-), stiffness (-), free fluid sign(-), mass (-), contraction (-).
Inspeculo : not performed
VT: not performed
Lab examination Hb: 12.9, WBC: 6.800, PLT: 376.000, HT: 37 PT 11.9 APTT 46.3 INR 1.0 Fibrinogen 257
LA 1 37.30 ANA - ACA IgM 5.3 ACA IgG 5.3
US ER -Single life fetus intrauterine
-GS 1.05 cm
-Fetal pole (-)
-FHR non visual
-C/ 4 weeks gestational age intrauterine

Diagnosis G3P0A2 4 weeks gestational age with threatened abortion + Antiphospolipid Syndrome Intrauterine

Planning Obs. Vital sign

Bedrest
Cygest 400 mcg/24h PR
Hystolan 10 mg/12 hours PO
Internal Dept Assessment