VI.

EMERGENCY ROOM REPORT

Monday, November 2nd, 2015 until Wednesday, November 4st, 2015
OBSTETRICS
Physiological patient
Pathological patient

: 3 cases
: 4 cases

GYNAECOLOGY
Total

: - case
: 7 cases

Emergency room chiefs

Dr. Astri Sri Widyastuti
Dr. Afan Novantri
Total

: 1 case
: - case
: 1 case

OBSTETRIC
No Initial Age
1.

Mrs.
YUL

23

2.

Mrs.
SUC

24

3.

Mrs.
SIS

27

4.

Mrs.
BAL

34

Diagnosis
G2P1A0 38 weeks gestational age not
inlabor with PROM 13 hours single
life fetus cephalic presentation
G5P2A2 30 weeks gestational age with
threatened preterm labor + APS was
suspected SLF cephalic presentation
G3P2A0 36 weeks gestational age not
inlabor with PROM 12 hours + prior
LSCS 1x SLF cephalic presentation
G4P3A0 39 weeks gestational age
inlabor 2nd stage with severe
preeclampsia SLF vertex presentation

CGH, RZM
Treatment
Physician
Plan for vaginal
delivery

CGH

Conservative
management

RZM

Conservative
management

RZM

Forcipal extraction

CGH

GYNAECOLOGY/ONCOLOGY

CGH,RZM

No

Initial

Age

Diagnosis

Treatment

Physician

OBSTETRIC
Dr. Astri Sri Widiastuty
3.11.15
Forcipal extraction due to severe preeclampsia
11:56 AM

Mrs. BAL/34/UA/CGH/BAR
D/ G4P3A0 39 weeks gestational age inlabor 2nd stage with severe preeclampsia
SLF vertex presentation

BP :
220/120mmHg
Protein : ++
GI : 8
HIII

01:15 PM
BP : 160/100
mmHg
GI : 6

M/ Stabilization 1 hour
Obs. Vital sign and FHR
IVFD RL xx gtt/m
Inj. MgSO4 protocol
Nifedipin 10mg/8 hour
Laboratory examination
Plan for vaginal delivery (Terminate 2nd stage with action)
Tubal ligation counseling
D/ G4P3A0 39weeks gestational age inlabor 2nd stage with severe preeclampsia
single life fetus vertex presentation
M/ Forcipal extraction
Episiotomy mediolateral

01:30 PM

Female life baby was born, BW 3800 g, BL 50 cm, A/S 8/9 FTAGA

01:40 PM

Placenta was delivered completely, PW 520 g, umbilical cord length 50 cm, 19x20 cm

Mother and baby was in good condition

FOLLOW UP
Nov 5th, 2015
07: 00 AM
Hb 9,1
Leu 22.600
Plt 434.000
LDH : 804

NO
1
2
3

D/ P4A0 post forcipal extraction due to severe preeclampsia with partial HELLP
syndrome day II
M/ -

Observation vital sign

Inj. Dexamethasone 10mg/12 hours IV
Methyl dopa 250mg/8 hours PO
Cefadroxil 500mg/12 hours PO
Mefenamic acid 500mh/12 hours PO
Tubal ligation

ASSESMENT
Dr. Astri Widyastuti
Report technique
Paper acknowledgment
Honesty
Mean

VALUE MAX
30
35
35
100

Notes

OBSTETRIC
Dr. Afan Novantri
-

Gynaecology Chief on Duty

Wednesday, November 4 , 2015 03.30 PM Thursday, November 5th, 2015 07.00 AM
Consultant on duty : dr. H. Rizal Sanif, SpOG (K)
5.11.15
Consult from Surgery Departement
Mrs.SRI/25/RA/AFN-RS
04.00 AM
D/ Acute Appendicitis was suspected
Lab :
US Confirmation (PB):
Leu 18.00
- Uterine shape and size was normal
- Non-visualized both ovaries
PT (-)
- There was Non- vascular mass at cavum duoglas
Alvorado
C/ Internal genitalia organ abnormality cannot be excluded yet
score : 5
Suggestion : US abdomen
10.30 AM
Abdominal Ultrasound
C/ Perforatated appendicitis was suspected
M/ There is no specific treatment from Obgyn Departement
Intraoperative consultation if there is abnormality finding during
laparotomy
5.11.15
Consult from Surgery Departement
Mrs.RIA/25/RA/AFN-RS
04.00 AM
D/ Acute Appendicitis was suspected
Lab :
US ER :
Leu 10.500
- Uterine shape and size was normal
- Both adnexa was normal
PT (-)
C/ There is no abnormality finding in genital interna organ
Alvorado
th

1.

2.

score : 3

M/ There is no specific treatment from Obgyn Departement

Other treatment according to Surgery Departement

NO
1
2
3

ASSESMENT
Dr. Afan Novantri
Report technique
Paper acknowledgment
Honesty
Mean

VALUE MAX
30
35
35
100

Notes