Anda di halaman 1dari 70

EMERGENCY ROOM REPORT

Friday, April 26th 2019

Chief on duty :
Dr. Santa Maria
Dr. Rakhmad Hidayat

Supervisor :
Dr. H. Iskandar Zulqarnain, OBGYN (C)
Recapitulation Emergency Room
Friday, April 19th – Thursday, April 25th 2019

Obstetrics Physiology 0 Patient


Patient
Pathology 2 Patients
Patient
Gynecology 6 Patients

Total Patient 8 Patients


RECAPITULATION
Friday, April 19th – Thursday, April 25th 2019

DATE OBSTETRICS GYNECOLOGY TOTAL

Friday, April 19th 2019 0 0 0

Monday, April 22th 2019 1 0 1

Tuesday, April 23th 2019 0 4 4

Wednesday, April 24th 2019 1 2 3

Thursday, April 25th 2019 0 0 1

Total 2 6 8
RECAPITULATION
Friday, April 19th – Thursday, April 25th 2019

Procedural AMOUNT %
LSCS 2 25
Medicinalis 2 25
Laparoscopy Operative 1 12.5
Curettage 2 25
Dilatation and Curettage 1 12.5

TOTAL 8 100
RECAPITULATION
Friday, April 19th – Thursday, April 25th 2019

Diagnose Amount % Procedure Amount %


Friday, April 19th 2019 - - - - - -
Preterm pregnancy with severe
Monday, April 22th 2019 preeclampsia + thyroid heart disease 1 12.5 LSCS + tubal ligation 1 12.5
decompensata
Ectopic pregnancy 1 12.5 Laparoscopy operative 1 12.5
Wednesday, April 23th Incomplete abortion 1 12.5 Curettage 1 12.5
2019 Endometriosis cyst 1 12.5 Medicinalis 1 12.5
Death conceptus 1 12.5 Dilatation and Curettage 1 12.5
Aterm pregnancy with prior CS 1x SLF 1 12.5 LSCS + tubal ligation 1 12.5
Thursday, April 24th 2019 Incomplete abortion 1 12.5 Curettage 1 12.5
Ovarian cancer stage IIIB + leukopenia 1 12.5 Medicinalis 1 12.5

Friday, April 25th 2019 - - - - - -

Total 8 100 % 8 100 %


EMERGENCY ROOM REPORT
Friday, April 19th – Thursday, April 25th 2019
OBSTETRICS
RESIDENT/
NO IDENTITY DIAGNOSIS ICD 10 PROCEDURE ICD 9 LAST DIAGNOSIS CONDITION
CONSULTANT
• Stabilization
• Vital sign observation,
contraction, FHR
• Anti hypertension
• Anti convulsion
• Lung maturation P1A0 post LSCS oi
G1P0A0 32 weeks • Laboratory examination maternal distress with
gestational age with severe • Urine catheterization severe preeclampsia +
Mrs.DEK/ O42.0 UFA
preeclampsia + thyroid • Internal Department thyroid heart disease
O41.0 74.1 Stable in
1. 22 Y.O/ heart disease Assessment, decompensata + SME
E05.91 66.3 ward
UA/ NS decompensata + Ophthalmology Pulmonary NS
E88.09
hypoalbumin SLF cephalic Department Assessment hypertension
presentation • Expectative management + hypoalbumin + post
• Evaluate ~ Gestosis Task tubal ligation
• Plan for consult to
Fetomaternal div.
• Plan for LSCS + tubal
ligation
EMERGENCY ROOM REPORT
Friday, April 19th – Thursday, April 25th 2019
OBSTETRICS
RESIDENT/
NO IDENTITY DIAGNOSIS ICD 10 PROCEDURE ICD 9 LAST DIAGNOSIS CONDITION
CONSULTANT
• Vital sign observation,
G2P1A0 39 weeks contraction, FHR
642.7 P2A0 post LSCS o/i prior UFA
Mrs. SRI/33 gestational age not inlabor • Laboratory examination Stable in
2 O20.0 650 CS 1x + prolonged latent DYT
YO/UA with prior CS 1x SLF cephalic • Plan for vaginal delivery ward
669.5 phase FY
presentation  TOLAC  failed 
plan for LSCS
EMERGENCY ROOM REPORT
Friday, April 19th – Thursday, April 25th 2019
GYNECOLOGY
RESIDENT/
NO IDENTITY DIAGNOSIS ICD 10 PROCEDURE ICD 9 LAST DIAGNOSIS CONDITION
CONSULTANT
• Vital sign
observation, bleeding
• Laboratory
examination, Hb
642.7 UFA
Mrs. ESI/ 28 serial Stable in
1. Ectopic pregnancy O00.9 650 Ectopic pregnancy DYT
YO/UA • Plan for US ward
669.5 AT
confirmation
• Plan for laparoscopy
operative (April 26th
2019)
• Vital sign
observation,
contraction, bleeding
• Tocolitic 642.7 UFA
Mrs. RIS/32 Post curettage o.i rest Stable in
2. Incomplete abortion O20.0 • Laboratory 650 SME
YO/UA of conception ward
examination, 669.5 AF
• Plan for US
confirmation
• Plan for curettage
EMERGENCY ROOM REPORT
Friday, April 19th – Thursday, April 25th 2019
GYNECOLOGY
RESIDENT/
NO IDENTITY DIAGNOSIS ICD 10 PROCEDURE ICD 9 LAST DIAGNOSIS CONDITION
CONSULTANT

• Vital sign
observation,
Dysmenorrhea c.b • Analgetic 642.7 UFA
Miss SOF/19 Endometriosis cyst
3. endometriosis cyst was N80.1 • Laboratory 650 Discharged SME
YO/UA was suspected
suspected examination, 669.5 FU
• Plan for US
confirmation

• Vital sign
observation,
• Laboratory
642.7 UFA
Mrs. ROF/ 31 examination, Post curettage oi Stable in
4. Death conceptus O00.6 650 DYT
YO/ RA • Plan for US death conceptus ward
669.5 AW
confirmation
• Dilatation and
Curettage
EMERGENCY ROOM REPORT
Friday, April 19th – Thursday, April 25th 2019
GYNECOLOGY
RESIDENT/
NO IDENTITY DIAGNOSIS ICD 10 PROCEDURE ICD 9 LAST DIAGNOSIS CONDITION
CONSULTANT

• Vital sign
observation, bleeding 642.7 UFA
Mrs. KOM/28 Post curettage o.i rest Stable in
5. Incomplete abortion N80.1 • Laboratory 650 SME
YO/UA of conception ward
examination, 669.5 AR
• Plan for curettage

• Vital sign
observation,
Ovarian cancer stage • Laboratory
642.7 UFA
Mrs. AYA/ 62 examination, Ovarian cancer stage Stable in
6. IIIB + O00.6 650 DYT
YO/ RA • General IIIB + leukopenia ward
DLI + leukopenia 669.5 AT
improvement
• Plan for internal
dept. Assesment
OBSTETRICS
Identity Mrs.DEK/22 YO/UA

Chief complain Preterm pregnancy with abdominal contraction, high blood pressure and history of hyperthyroidism
22.04.2019 at Since 12 hours before admitted to hospital, patient complained about abdominal contraction (+) irregularly,
01.00 PM history of bloody show (-), history of amniotic leakage (-), history of leuchorrea (+), history of trauma (-), history of
History massage on abdomen (-), history of post coital (-), history of toothache (-), history of fever (-), history of
consuming medications or potions (-). History of hypertension in this pregnancy (-), history of hypertension before
pregnancy (-), History of hypertension on family (-), headache (-), vomit and nausea (-), blurry vision (-), epigastric
pain (-). History of hyperthyroidism since 2016 but taking medication was not routine. Patient admit that her
pregnancy was preterm and fetal movement (+).
Marital status 1x, 6 months
Reproduction status Menarche since 11 yo, regular cycle, 28 days, 4 days, LMP: 19-09-2018
Obstetric history 1. Current pregnancy

Past illness history 22/04/2019 hospitalization at Banyuasin Hospital with diagnosed G1P0A0 32 weeks gestational age with
threatened preterm labor and history of hyperthyroidism SLF cephalic presentation and has been given
utrogestan 100 mg/ 12 hours PO, paracetamol 500mg/8 hours PO
2 months ago, patient was given PTU 100mg/ 24 hour PO from Banyuasin Hospital but she was not
routinely taken
General BP: 160/110 mmHg, P: 102 x/m; R: 20 x/m, T: 36,9⁰C Weight: 60 kg Height: 159 cm
Obstetrical examination Palpation: Uterine fundus ½ proc. Xyphoideus to umbilicus (24 cm), longitudinal lie, left back, head U
GI: 6 5/5,contraction 1x/10’/15” , FHR 155 x/m, EFW 1705 g
TI: 1 Insp : portio livide, edema (+), OUE was closed, flour (+), fluxus (-), erosion/laceration/polyp (-),
Extremitas: Edema pretibial (+)/(+)
Identity Mrs.DEK/22 YO/UA
Laboratory Hb: 13.1 RBC: 4.540.000 WBC: 7.050 HT: 39 PLT: 177.000
11-04-2019 RDW-CV: 14.60 DC: 0/0/65/28/7 FT4: 2.48 TSHs: 0.0008
11.01 AM
US ER (SME) - SLF cephalic presentation
- BPD: 8.03 cm AC: 26.76 cm EFW: 1693 g
- HC: 29.06 cm FL: 5.91 cm
- Placenta on posterior corpus of uterine
- Amniotic fluid enough
C/ 32 weeks gestational age SLF cephalic presentation
Diagnosis G1P0A0 32 weeks gestational age with severe preeclampsia + threatened preterm labor + uncontrolled hyperthyroidism SLF
cephalic presentation

Therapy • Expectative management


• Stabilization 1-3 hour
• Observed vital sign, FHR, uterine contraction
• Laboratory examination
• IVFD RL xx dpm
• Urine Catheterization, fluid balance monitoring
• MgSO4 40% ~ protocol
• Nifedipine 10mg/ 8 hours per oral
• Evaluation ~ gestosis task
• Internal, Ophthalmology Department Assessment
Laboratory Hb: 15.5 RBC: 5.120.000 WBC: 7.170 HT: 45 PLT: 220.000 RDW-CV: 15.60 DC: 0/1/59/33/7 Bill.tot: 1.20 SGOT: 38
22-04-2019 SGPT: 21 LDH: 335 Albumin: 1.8 GDS: 85 Uric acid: 10.2 Cr: 0.65 Ur: 66 Mg: 3.00 Ca: 7.0 Na: 138 K: 5.2
02.38 PM Urinalisa  Pro: (+) Glu (-) Ket (-) Blo(-) Bil(-) Nit (-) LEA (-)
Identity Mrs.DEK/22 YO/UA
Assesment Internal Dept. A/ Hyperthyroidism in pregnancy, DD/ thyroid heart disease + Hypertension in pregnancy + Hypoalbumin + hypocalsemia
IBWS: 20 P/ - Plan for echocardiography
- Temp: 0 - PTU 100mg/8 hours PO
- CNS: 0 - CaCO3 500mg/8 hours PO
- GH dysfunction: 0 - Metyldopa 250mg/ 12 hours PO
- HR: +15
- Albumin 20% fls/ 24 hours IV
- CHF: +5
- AF: 0
Assesment Ophtalmology Dept. A/ There was no sign of retinopathy and choroidopathy hypertension

Follow Up A/ G1P0A0 32 weeks gestational age with severe preeclampsia + threatened preterm labor + Hyperthyroidism in pregnancy, DD/
04.00 PM thyroid heart disease + Hypoalbumin + Hypocalsemia SLF cephalic presentation

BP: 140/90 mmHg, P/


P: 127 x/m; R: 20 x/m, • Expectative management
T: 36,9⁰C • Observed vital sign, FHR, uterine contraction
GI 4 • IVFD RL xx dpm
• Urine Catheterization, fluid balance monitoring
Palpation: Uterine fundus ½ • MgSO4 40% ~ protocol
proc. Xyphoideus to • Nifedipine 10mg/ 8 hours per oral
umbilicus (24 cm), • Evaluation ~ gestosis task
longitudinal lie, left back, • Plan for echocardiography
head U 5/5, contraction • Plan for consult to Fetomaternal div.
1x/10’/10” , FHR 143 x/m, • PTU 100mg/8 hours PO
EFW 1705 g • CaCO3 500mg/8 hours PO
• Metyldopa 250mg/ 12 hours PO
• Albumin 20% fls/ 24 hours IV
Identity Mrs.DEK/22 YO/UA
Follow Up A/ G1P0A0 32 weeks gestational age with severe preeclampsia + threatened preterm labor + Hyperthyroidism in pregnancy, DD/
23.04.2019 thyroid heart disease + Hypoalbumin + Hypocalsemia SLF cephalic presentation
06.00 AM
P/
BP: 110/70 mmHg, • Expectative management
P: 127 x/m; R: 20 x/m, • Observed vital sign, FHR, uterine contraction
T: 36,9⁰C • IVFD RL xx dpm
GI 4 • Urine Catheterization, fluid balance monitoring
• MgSO4 40% ~ protocol
Palpation: Uterine fundus ½ • Nifedipine 10mg/ 8 hours per oral
proc. Xyphoideus to • Evaluation ~ gestosis task
umbilicus (24 cm), • Plan for echocardiography
longitudinal lie, left back, • Plan for consult to Fetomaternal div.
head U 5/5, contraction • PTU 100mg/8 hours PO
1x/10’/10” , FHR 143 x/m, • CaCO3 500mg/8 hours PO
EFW 1705 g • Metyldopa 250mg/ 12 hours PO
• Albumin 20% fls/ 24 hours IV
Echocardiography • HVK, THD
• Pulmonary hypertension
• Preserved function
Identity Mrs.DEK/22 YO/UA
Follow Up A/ G1P0A0 32 weeks gestational age with severe preeclampsia + Pulmonary hypertension
24.04.2019 + thyroid heart disease decompensata + hypoalbumin SLF cephalic presentation
06.00 AM
P/
BP: 110/70 mmHg, • Expectative management
P: 127 x/m; R: 20 x/m, • Observed vital sign, FHR, uterine contraction
T: 36,9⁰C • IVFD RL xx dpm
GI 4 • Urine Catheterization, fluid balance monitoring
• MgSO4 40% ~ protocol
Palpation: Uterine fundus ½ • Nifedipine 10mg/ 8 hours per oral
proc. Xyphoideus to • Evaluation ~ gestosis task
umbilicus (24 cm), • PTU 100mg/8 hours PO
longitudinal lie, left back, • CaCO3 500mg/8 hours PO
head U 5/5, contraction • Metyldopa 250mg/ 12 hours PO
1x/10’/10” , FHR 143 x/m, • Albumin 20% fls/ 24 hours IV
EFW 1705 g • Plan for LSCS

Laboratory PT 12.5 APTT 29.7 Albumin 2.4 FT3 1.78 ( 1.71-3.71) FT4 1.53 ( 0.70-1.48) TSH 0.0054 ( 0.35-4.94)
24-04-2019
06.37

24.04.2019 14.50 WIB. Female, life neonatus was born, with birth body weight 1500 g, body lenght: 41 cm, APGAR score 7/9
Operation Report 15.00 WIB, placenta was delivered complete, placental weight: 370 grams, umbilical cord length 26 cm ø 15x14
cm

A: P1A0 post LSCS o/i maternal distress with severe preeclampsia + thyroid heart disease decompensata +
hypoalbumin + post tubal ligation
Mrs.DEK/22 YO/UA
Procedure Case Outcome
LSCS Mrs.DEK/22 YO/UA 02.40 PM : Operation started
Patient on supine position and on spinal anesthesia. Aseptic and antiseptic on
ICD 10 Preop diagnosis: operating area Pfannensteil incisionwas performed. After peritoneum was
O42.0 G1P0A0 32 weeks gestational age not inlabor with opened, there was uterine size as preterm pregnancy, amniotic fluid(+), clear, odor
O41.0 severe preeclampsia + thyroid heart disease (-)
E05.91 decompensata + Pulmonary hypertension 02.45 PM female life baby was born with BW 1500 g BL 41 cm A/S 7/9 PTAGA
E88.09 + hypoalbumin SLF cephalic presentation Placenta born completely
Uterine closed with continuous suture with PGA 1.0
Performed tubectomy pomeroy
ICD 9-CM Ensured there was no active bleeding, abdominal wall was closed layer by layer.
74.1 Post op diagnosis: Bleeding intraoperative 300 cc, urine 200 cc clear.
66.3 P1A0 post LSCS oi maternal distress with severe
preeclampsia + thyroid heart disease decompensata + 03.20 : Operation over
Pulmonary hypertension
OP : NS/SIY/RNI/KAR + hypoalbumin + post tubal ligation
Identity Mrs. SRI/33 YO/UA 24-04-2019 09.00 AM
Chief complain Fullterm pregnancy inlabor with prior CS 1x
History ±6 hours before admitted to hospital, patient complained about abdominal contraction (+) irregularly, bloody
24-04-2019 show (-),amniotic leakage (-), fever (-), toothache (-), skin infection (-), abdominal contraction (+). H/ bloody show
09.00 AM (-). H/ trauma (-), H/ abdominal massage (-), H/ post coital (-). Patient went to OBGYN with diagnose G2P1A0 38
weeks gestational age not inlabor with prior CS 1x SLF cephalic presentation then referred to RSMH
She admitted that her pregnancy was fullterm and fetal movement (+)
Marital status 1x, 6 years
Reproduction status Menarche since 11 yo, regular cycle 28 days, 5 days, LMP: July 25th 2018

Obstetric history 1. 2014, male, 2900 grams, SC oi breech presentation, Pertamina Hospital, healthy
2. Current pregnancy
Phisical examination BP : 120/80 mmHg, HR :80x/m, RR: 24x/m, T: 36,5ºC

Obstetrical Palpation: Uterine fundus 3 finger below proc. Xyphoideus (33 cm), longitudinal lie, left back, head U 5/5,
Examination contraction (-), FHR 150 x/m, EFW 3100 g

VBAC score: 3  77% Vaginal toucher: portio soft, posterior, eff 0 %, Ø closed, H I, amniotic membrane, denominator cannot be assest

Laboratory examination Hb: 12.4 Ht: 37 WBC: 8.610 PLT: 264.000


24-04-2019
Identity Mrs. SRI/33 YO/UA 24-04-2019 09.00 AM
US ER (DYT) - SLF cephalic presentation
- BPD: 9.07 cm AC: 31.77 cm EFW: 2908 g
- HC: 32.82 cm FL: 7.22 cm TCD: 5.47cm ⁓ 38w1d
- Placenta on fundus of uterine
- Amniotic fluid sufficient, SDP 5.19 cm
- SBR thickness 1.13 cm
C/ 39 weeks gestational age SLF cephalic presentation
Diagnosis G2P1A0 39 weeks gestational age not inlabor with prior CS 1x SLF cephalic presentation

Therapy • Observation of vital signs, contraction, FHR


• IVFD RL xx/minute
• Laboratory examination
Report to Consultant incharge : (DR. Dr. H. Ferry Yusrizal, SpOG (C)M.Kes)
• Plan for vaginal delivery  TOLAC
Identity Mrs. SRI/33 YO/UA 24-04-2019 09.00 AM
Follow up S/inlabor with prior CS 1x
24-04-2019 Palpation: Uterine fundus 3 finger below proc. Xyphoideus (33 cm), longitudinal lie, left back, head U 4/5,
11.00 PM contraction 2x/10’/25”, FHR 140 x/m, EFW 3100 g
VT: portio soft, posterior, eff 100 %, Ø 2 cm, H I-II, amniotic membrane (+), denominator transverse sagitalis
suture

Diagnosis G2P1A0 39 weeks gestational inlabor first stage latent phase (prolonged latent phase) with prior CS 1x SLF cephalic
presentation
Therapy • Observation of vital signs, contraction, FHR
• IVFD RL xx/minute
Report to Consultant incharge : (DR. Dr. H. Ferry Yusrizal, SpOG (C)M.Kes)
• Plan for LSCS
25.04.2019 09.00 AM : Male, life neonatus was born, with BBW: 3900 g, BL: 51 cm, APGAR score 8/9
08.55 AM 09.03 AM : Placenta was delivered complete, PW: 550 grams, UCL: 48 cm ø 17 x 18 cm
Operation Report
A: P1A0 post LSCS o/i prior CS 1x + inertia uterine
GINEKOLOGI
Identity Mrs. ESI/ 28 YO/UA 23-04-2019 01.50 PM
Chief complaint Early pregnancy and abdominal pain

History 1 day before admission patient complained about abdominal pain. H/ vaginal spotting, 1-2x change pads. Reddish. History of
23-04-2019 abdominal massage (-), post coital (-), leucorrhea (+), trauma, tootache (-), history taking traditional medicine (-). Patient came to
(01.50 PM) OBGYN with diagnosis ectopic pregnancy and planned to laparoscopy operative, then reffered to RSMH.

Marital status 1x 4 years

Reproduction status Menarche since 14 yo, irregular cycle, lasts 7 days, LMP: forgot

Obstetric history 1. 2017, female, 3200 g, CS oi anhydramnios, Myria Hospital, healthy


2. this pregnancy

Past iIlness history Curettage (05-04-2019) in Charitas Hospital, No: PA/2019/00643, C/ hyperplastic endometrial polyp dd/ rest of pregnancy reaction
with endometritis
Physical Examination BP: 120/80 mmHg Pulse : 90 x/m T: 36.8oC RR: 18x/m

Obstetrical examination Palpation: flat abdomen, tenderness (-), mass (-), Pain (+), free fluid sign (-)
Inspeculo : livide portio, closed OUE, fluor (-), fluxus (+) with no active bleeding, E/L/P (-), culdosintesis(-)
VT : soft portio, closed OUE, left and right adnexa parametrium was normal, douglas pouch was protrude, cervical motion
tenderness (+)
PT test (+)
US ER (DYT) - uterine AF size and shape normal, 8.14 x 3.31 cm in size
- Endometrial line (+), 0.57 cm
- in left adnexa there was hipechoic mass, 7.00 x 5.16 cm in size
- right ovary was normally, 2.53 x 1.70 cm in size
- C/ left adnexa mass was suspected
Identity Mrs. ESI/ 28 YO/UA 23-04-2019 01.50 PM
Diagnosis Ectopic pregnancy
Therapy Observation of vital signs, vaginal bleeding
IVFD RL gtt XX/m
Laboratory examination  Hb serial
Plan for laparascopy operative  April 26th 2019
Plan for US confirmation

Lab Examination Hb I: 11.8 g/dL, WBC: 8.600/mm3, PLT: 418.000/mm3


Hb II: 11,6 g/ dL
Hb III: 11,6 g/dL
US confirmation - Uterine AF size and shape enlarged, 5.4 x 4.22 cm in size
Dr Abarham Martadiansyah, - Endometrial line thickened 1.24 cm in size, homogenous myometrium, regularly basal stratum
SpOG(C) - Desidualization (+)
24-04-2019 - Invisible intrauterine gestational sac
- in posterior uterine (CD) there was complex mass, 6.91 x 6.3 cm in size
- C/ ectopic pregnancy was suspected + hematocele
US CONFIRMATION
Identity Mrs. RIS/32 YO/UA 23-04-2019 01.00 PM
Chief complaint Early pregnancy with vaginal bleeding
History 1 day before admitted patient complained about vaginal bleeding (+), abdominal contraction (-), History of
23-04-2019 leucorrhea (-). History of trauma (-), history of drugs (-). History of fever (-). History of post coital (+). History of
(01.00 PM) out eyelets (-). History of out of conception (-). History of no menstrual period (+) 1 months, history of breast
tense (+)
Marital status Married 1 time, 5 years
Reproduction status Menarche since 14 yo, reguler cycle 28 days, 4 days, LMP forgot (±05-03-2019)
Obstetric history 1. 2014, male, 3200 g, Spontaneous delivery, RSMH, healthy
2. This pregnancy
Past iIlness history (-)
Physical Examination Vital sign: BP = 120/70mmHg, HR = 83x/m, temp = 36,5 C, RR = 20 x/minute
Gynecologic Palpation : Abdominal enlargement, symmetric, tenderness (-), ballottement (-), fundal height cannot to palpable,
examination mass (-),
Insp: portio livide, closed oue, fluor (-), fluxus (-), E/L/P (-)
VT: soft portio, medial, no dilatation, eff 0%, both of adnexa were normal, both parametrium wasn’t tense, corpus
uterine ~ 5 weeks gestational age, Douglas pouch not bulging
US ER (DYT) - There was Gestational Sac intrauterine, 1.45 cm ⁓5w5d
C/ 5 weeks gestational age intrauterine
Identity Mrs. RIS/32 YO/UA 23-04-2019 01.00 PM
Diagnosis G2P1A0 5 weeks gestational age with threatened abortion intrauterine
Therapy • Hospitalized
• Bedrest
• Observation of vital signs, contraction, bleeding
• Laboratory examination
• Cygest 400mcq/24 hours pv
• Histolan 10 mg/12 hours po
• Plan for US Confirmation
Lab examination Hb: 12.9 g/dl, WBC: 8.640/ mm3, PLT 224.000/mm3, HT: 39%,
US confirmation - There was Gestational Sac intrauterine, 1.32 cm in size
Dr Abarham Martadiansyah, C/ 4 weeks gestational age intrauterine
SpOG(C)
Identity Mrs. RIS/32 YO/UA 23-04-2019 01.00 PM
Follow up S/ Vaginal bleeding
25-04-2019 Palpation : abdomen flat, symmetrical, uterine fundal not palpable, ballottement externa (-), stiffness (-), free fluid sign (-)
03.00 AM contraction (-),
Inspeculo : portio livide, OUE opened 2cm, Tissue was seen on OUE. fluor (-), fluxus (+) no active bleeding, E/L/P (-)
Vital sign: A/ Incomplete abortion
BP = 120/70mmHg, P/ Observation of vital signs, contraction, FHR
HR = 83x/m, temp = 36,5 C,
• IVFD RL xx/minute
RR = 20 x/minute
• Plan for US confirmation
US confirmation - There was irreguler Gestational Sac intrauterine in OUI ⁓ inevitable abortion
Dr Abarham Martadiansyah, - Fetal pole (-), fetal echo (-)
SpOG (C) C/ inevitable abortion
P/ plan for curettage

25.04.2019 09.00 PM operation begin


09.00 PM Patient on lithotomy position, on general anesthesia. Do aseptic and antiseptic.
Operation Report Field operation narrowing with sterile cloth, do catheter insertion, upper and lower sims were inserted, sondage uterus AF 10 cm,
E/L/P (-)
Then performed curettage :
Amount of blood +30 cc and tissue + 50cc  sent to PA
09.30 PM Operation done

A/ post curettage o/i rest of conseption


Follow Up Stable in ward
US CONFIRMATION
US confirmation 25-04-2019
Identity Mrs. ROF/ 31 YO/ RA 23-04-2019 01.30 PM
Chief complaint Early pregnancy with vaginal spotting and prior CS 1x
History 3 hours before admitted patient complained about vaginal spotting, 1-2x change pads. reddish. abdominal pain (-),
23-04-18 History expulse tissue like cystic part (-), of abdominal massage (-), post coital (-), leucorrhea (-), history of trauma (-)
01.30 PM , history of tootache (-), taking herbal medicine (-), history of breast tense (+), history of amenorea 3 weeks (+). She c
ame to OBGYN then reffered to RSMH.
Marital status 2x . 1) 10 years, 2) 2 years
Reproduction status Menarche since 13 yo, regular cycle 28 days, 6 days. LMP : 27-01-19
Obstetric history 1. 2009, female 3000gr, spontaneous delivery, midwife, Healthy
2. 2014, male 3500gr, LSCS oi PPT, Kundor Hospital , Healthy
3. This pregnancy

Past iIlness history (-)

Vital Sign BP 110/70 Pulse : 96 x/m T: 36.5 RR: 24x/m


Obstetrical examination Palpation: Abdomen flat, symmetric, no tense, Fundal height difficult to palpate, mass (-), free fluid sign (-),
Inspeculo : portio livide, OUE was closed, fluor (-), fluxus (+) no active bleeding, E/L/P -
US ER • Uterus AF
• GS (+) at scar of pregnancy, 2.82 x 1.93 x2.42 cm in size
• Both of ovarium in normal limit
C/ 7 weeks of gestational age intrauterine of scar of pregnancy
Identity Mrs. ROF/ 31 YO/ RA 23-04-2019 01.30 PM
Diagnose G3P2A0 7 weeks gestational age with Ectopic Caesarean Scar pregnancy was suspected intrauterine

Therapy • Hospitalized
• Bedrest
• Observation of vital signs, contraction, bleeding
• Laboratory examination
• Cygest 400mcq/24 hours pv
• Histolan 10 mg/12 hours po
• p/ US Confirmation
Lab examination Hb: 13.3 g/dl, WBC: 8.380/ mm3, PLT 219.000/mm3, HT: 38%,

US confirmation • There was Gestational Sac intrauterine, 3.14 cm in size ⁓ 8W1D


• There was Yolk Sac, 1.24 cm in size.
• CRL 0.4 cm in size ⁓ 6W1D
• Pulasasi (-)
• There was trophoblast nidation in myometrium
C/ Death conceptus (invasion near with cesarean section scar, but implantation of myometrium)
25.04.2019 12.30 PM operation begin
12.30 PM Patient on lithotomy position, on general anesthesia. Do aseptic and antiseptic.
Operation Report Field operation narrowing with sterile cloth, do catheter insertion, upper and lower sims were inserted, sondage uterus AF 10 cm,
E/L/P (-)
Then performed curettage :
Amount of blood +70 cc and tissue + 50cc  sent to PA
13.00 PM Operation done

A/ post curettage o/i Death conceptus


US CONFIRMATION
Identity Miss SOF/19 YO/UA 23-04-2019 12.30 PM
Chief Complain Vaginal bleeding and menstrual pain
History Since 1 year ago she complained of vaginal bleeding and menstrual pain, 4x changing pad/ days. Patient also felt pain
23-04-2019 when menstruation. Pain was felt to disrupted activity. Urination and defecation were normal. History of vaginal
12.30 PM bleeding outside menstrual cycles (+). post coital bleeding (-) , leucorrhea (-), decrease of appetite (-), She was came to
obstetrician and told there was a endometriosis cyst was suspected.
Marital Status Not yet
Reproduction Menarche since 12 yo, irregular cycles, LMP forgot
Obstetric History P0A0
General BP: 90/60 mmHg, P: 88 x/m; R: 22 x/m, T: 36,5⁰C Weight: 51 kg Height: 155 cm
Gynecology Palpation: Abdomen flat, symmetric, no tense, Fundal height unpalpable, mobile, free fluid sign (-).
Examination Inspeculo: no performed
VT: no performed
US (NS) C/ uterine AF size and shape normal, 7.43 x 3.65 cm in size
23-04-2019 - Endometrial line (+) 0.94 cm
- Portio and endocervix was normally
- Right ovary enlarge, there was hipoechoic with internal echo, possibly a right endometriosis cyst (rupture was
suspected)
- Left ovary was normally
Identity Miss SOF/19 YO/UA 23-04-2019 12.30 PM
Diagnosis Dysmenorrhea cb endometriosis cyst was suspected

Therapy • Hospitalized
• Observation of vital signs, contraction, bleeding
• Laboratory examination
• Paracetamol 500mg/8 hours IV
• p/ US Confirmation
Laboratory result Hb: 13.1, WBC: 10.710, RBC: 4.770.000, HT: 39%, RDW-CV: 13.90, DC: 0/2/79/15/4

US confirmation / uterine AF size and shape normal, 6.66 x 3.68 cm in size


Dr Abarham - Endometrial line (+) 12.95 cm, homogenous myometrium, regularly basal stratum
Martadiansyah, SpOG(C) - Portio and endocervix was normally
- Right and Left ovary was normally
- On right adnexa, there was cystic mass bordering of other organ, accompanied pseudocyst (c.b rupture of the cyst was suspected)
C/ pseudocyst (c.b rupture of the cyst was suspected)
US Confirmation
IDENTITY Mrs. KOM/28 YO/UA 24-04-2019 02.29 PM
Chief complain Early pregnancy with abdominal pain and vaginal bleeding

History 5 hours before admission, patient complained abdominal contraction (+), bloody show (+), 2x napkins changed. History of :
Hospitalized : trauma (-), leucorrhea (-), post coital (-), toothache (-), skin infection (-), traditional herbal drink (-), traditional massage in
24-04-2019 abdominal (-), fever(-), breast tenderness (+).
02.29 PM Patient admitted that her pregnancy was early and she was pregnant for 3 months

Marital status 1x, 4 years


Reproduction status Menarche since 14 yo, regular cycle 28 days, for 7 days, LMP : 14-01-2019
Obstetric history 1. 2014. Male. 2600g. Aterm. Spontaneous delivery. Midwife. Healthy
2. Current pregnancy

Physical examination BP : 110/70 mmHg, P : 84 x/min, T : 36.3 C, RR : 20 x/min


Obstetrical examination Palpation : abdomen flat, symmetrical, uterine fundal not palpable, ballottement externa (-), stiffness (-), free fluid sign(-)
contraction (-),
Inspeculo : portio livide, OUE opened 2cm, Tissue was seen on OUE. fluor (-), fluxus (+) no active bleeding, E/L/P (-)
Laboratory examination Hb: 14.8 g/dl, WBC 9.380/ mm3, Platelet 247.000/mm3, Ht 42%
Plano test (+)

Diagnosis Incomplete abortion


Therapy Observation of vital signs, contraction, FHR
Bedrest
IVFD RL xx drops/m
Report to Consultant incharge : (Dr. H. Azhari, SpOG (C))
R/ Curretage
Mrs. KOM/28 YO/UA 24-04-2019 02.29 PM

Procedure Case Outcome


Curettage Mrs. KOM/28 YO/UA 06.10 PM: Operation started.
•Patient on Lithotomy position and on TIVA
ICD 10 •Aseptic and antiseptic on operating area.
O03.4 Preop diagnosis:
•Performed Sims inferior installation.
Incomplete Abortion
ICD 9-CM •Portio was seen avoe.
69.02 •Performed tenaculum installation at portio at 11
Post op diagnosis: a clock.
Post curettage o.i •Performed curettage in uterine cavity. Amount
OP : AR Incomplete Abortion of blood +30 cc and tissue + 50cc
•After it is believed to be clean and no tissue
and no bleeding, tenaculum was released
•Portio cleaned with bethadine
06.40 PM: Operation was finished.
Identity Mrs. AYA/ 62 YO/ RA APRIL, 24th 2019 12.10 PM

Chief complaint Body weakness and vomitus

History 3 days before admitted, patient was complaint about body weakness, nausea (+), vomit (+), anorexia
(+), lower extremities pain (+). VAS score : 6. history of HTSOB (Nov 2018) with PA result (517/A/2019)
- Malignant epitelial tumor, DD/ clear cell of ovarian cancer, high grade serrous cystadenocarcinoma
ovarium. History of chemotherapy series V

Marital status 1x, 22 years

Obstetric history P3A1

Medical History History of chemotherapy Doce – carbo V series (16/4/2019)


History of HTSOB (Nov 2018)
Gynecology Inspection : Abdomen flat, simetry, tenderness (-), free fluid sign (-), mass (-)
examination Inspeculo : vaginal stump was normal
VT : vaginal stump was normal
RT : TSA good, mucous was normal, empty ampula recti, intralumen mass (-)
Identity Mrs. AYA/ 62 YO/ RA APRIL, 24th 2019 12.10 PM

US ER (Dr. Abarham •Uterine non visual -> HT


Martadiansyah, SpOG •Non visual left ovarian SOB
(C)) •Cervical stump was normally
09-04-2019 •Kidney in normal limit
•liver in normal limit
•There was no abnormal mass in abdominopelvic cavity
•Ascites (-)
•C/ There was no abnormal mass in abdominopelvic cavity

Laboratory Hb 10.0, Wbc 660, PLT : 209.000, SGOT 13, SGPT 8, Ca 9.0 Na 133 K 5.1 AFP 0.96 CEA 3.20 CA 125 16.1
Examination
Diagnosis Ovarian cancer stage IIIB + obs. Vomitus + leukopenia

Therapy •Observation of vital sign


•IVFD RL xx/m
•Lab examination
•Ondancetron 8mg/12 hours
•Assessment of internal department  Inj Leucogen 300mcg SC
THANK YOU