Beruflich Dokumente
Kultur Dokumente
Residents
ER Team April 2017
Reporting
4 Procedures:
• 2 Vaginal deliveries
• 1 Cesarean section
• 1 Laparotomy Exploration Adhesiolysis, Evacuation
Multiple Pocket Abcess, Omentectomy, Total
Hysterectomy, Left Salpingoophorectomy, and
Right Salpingectomy
Procedure No Case Outcome
Vaginal 1 Mrs. V, 28 yo Baby boy, 3180 gram, 49 cm, AS 8/10
Delivery MR 4092481 BS ~ 38 weeks
Placenta born completely
ICD 10 perineal rupture grade II
Latent phase of labor on G6P1A4 38 wga, singleton perineorraphy
O80.0 live head presentation, Anti Phospolipid Syndrome
Z37.0 FP : IUD PP
D68.61
APS criteria:
ICD 9 CM Clinical
Process: 1. Spontaneous abortion, 12 wga, fetus
73.59 Latent phase of labor, Normal CTG observation 8 (+), 2007
88.78 hours active phase of labor ; contraction 2. 9 yo, girl, 3600 gram, spontaneous,
75.34 4x/10’/45”, 6 cm, amniotic membrane (+), head midwife, 2008
69.7 on hodge III observation 2 hours 2nd Stage of 3. Spontaneous Abortion, 8 wga, fetus
labor (+), 2008
4. Abortion, 8 wga, performed
curettage, fetus (+), 2015
5. Spontaneous Abortion 8 wga, fetus
(+), 2016
Laboratory
BC (ANC at High Risk Clinic RSCM) Positive Lupus anti coagulant at
December 2015 and September 2016
Lucas (T1B)
Independent Mother and baby are in good condition in
the ward, plan to be discharged
Procedure No Case Outcome
Vaginal delivery 2 Mrs. F, 30 yo Girl, 3600 gram, 50 cm, AS 8/10
MR 3896239 BS ~ 40 wga
ICD 10 Clear amniotic fluid
O80.0 Placenta born completely
Z37.0 Active phase of labor on G2P1 40 wga, singleton live Episiotomy ~ perineal rupture grade II
head presentation perineorraphy
N25.8 Mother with renal tubular acidosis
ICD 9-CM
73.59
88.78 ANC Data:
75.34 2014: Recurrent hypokalemia, acidemia (pH 7,3), low
69.7 HCO3 (14), hyperchloremia (121) ~ Renal Tubular FP: IUD PP
Acidosis Bicarbonate and KSR medication
Process:
8 cm, his 4x/10’/45” observation 1 hours
second stage of labor
NBC:
David (T2A) Mother and baby are in good condition in
Referred from midwife with waterbroke
Independent the ward, rooming in.
Procedure No Case Outcome
Laparotomy 4 Mrs. TWA, 26 yo Patient in supine position under general
Exploration MR 4209244 anesthesia
Adhesiolysis, A and antiseptic at operating site
Evacuation Multiple
Pocket Abcess, Preoperative diagnosis:
Omentectomy, Total POD 32 on P1 Post C-Section due to Failed
Hysterectomy, Left Induction, PROM, with problems:
Salpingoophorectomy, 1. Sepsis due to CIAI (SOFA Score 1)
and Right 2. Hypokalemia (2.9)
Salpingectomy 3. Hypoalbuminemia (2.99)
4. Hypomagnesemia
ICD 10 5. Hypocalcemia
O98.9 O90.0
N74.8 E87.6
A41.9 E 88 Post operative diagnosis:
Deep Surgical Site Infection, Multiple pocket
ICD 9-CM abscess, tubo ovarian abscess, Uterine wound
88.78 68.49 dehiscence
66.4 99.0
54.59
Ogi (Chief) /
Richie (Chief) /
Dr. Romi, OBGYN /
Dr. Subandi, OBGYN / NBC
Digestive Department Referred from Urip Sumohardjo Hospital, Patient is in ICU 2nd floor spontaneous
Lampung due to peritonitis, , POD 32 on P1 breathing with simple mask 8 lpm,
Post C-Section adequate contact
Cranial Cranial
Cranial
Cranial
Mrs. TWA, 26 yo
MR 4209244
1. 1. Sepsis due to Deep Surgical Site
Post Laparotomy Exploration Infection, Multiple pocket abscess,
Adhesiolysis, Evacuation Multiple tubo ovarian abscess, Uterine wound
Pocket Abcess, Omentectomy, Total dehiscence (SOFA Score 1)
Hysterectomy, Left 2. Hypoalbuminemia (1.81)
Salpingoophorectomy, and Right 3. Hypokalemia (2.9)
Salpingectomy
Today Condition
April 5th, 2017, 06.00
Fluid Balance
ICU 2nd floor
Adequate contact
S: operation site pain VAS 2-3 4/4/17 – 5/4/17
GCS E4M5VX BP : 124/80(99) mmHg , HR 106 x/min, temp 36.80C, 06.00 – 06.00
RR 21x/min, O2 Sat 100% on simple mask Input 5208 cc
Output 3697 cc
General status:
Balance +1511 cc
Eye: CA (-/-), SI (-/-)
Heart: S I-II N , murmur (-) gallop(-) Diuresis 1,1 cc/kgBW/hour
Lung: Vesicular +/+, rhales -/-, wheezing -/-
Abdomen: no distention, bowel movement (+)
Extremity: warm, CRT<2”, edema (-/-)
Gynecological state :
I: V/U wnl, no active bleeding
Surgical site : no bleeding and pus
Transfusion
Vital Chart PRC 607 cc
FFP 190 cc
4/4/2017 – 5/4/2017
160 Operating Theatre
Bleeding 600 cc
Urine 500 cc
140
120
100
80
60
40
20
0
6 8 10 12 14 16 18 20 22 24 2 4 6
PCT <0.5
5/4/17
Lab 4/4/17 5/4/17
examinati Normal Range
on
Artery Artery Vein