Emergency Room Report

Thursday, July 18th 2019

Resident On Duty:
Dr. Sartika Nopradilova

Chief on Duty:
Dr. Fitrah Tindar A

Supervisor:
Dr. H. Iskandar Zulkarnain, SpOG (K)
Recapitulation Emergency Room
Thursday, July 18th 2019
Obstetrics Physiology Patient 0 Patient
Pathology Patient 1 Patients

Gynecology 2 Patients
Total Patient 3 Patients
 EMERGENCY ROOM REPORT
Thursday, July 18th 2019
Obstetrics

No IDENTITY DIAGNOSIS ICD 10 PROCEDURE ICD 9 PHYSICIAN

• Expectative management V72.6

G2P1A0 29 weeks gestational age not inlabor O99.019 • Observation of Vital sign,
2 SAR
1
Mrs. FEB/ 36 with severe anemia + prior CS 1x (o.i breech O34.21 • uterine contraction, FHR
Lung Maturation FTA
YO / UA / NS presenation + anhidramnion) + rhesus O36.0191 • Consult to hematology 659.8 NS
negative mother SLF transverse lie O32.2 department
• PRC tranfusion V58.2
 EMERGENCY ROOM REPORT
Thursday, July 18th 2019
Gynecology

No IDENTITY DIAGNOSIS ICD 10 PROCEDURE ICD 9 PHYSICIAN

• Observation of Vital sign

Mrs. NEL / 38 • Laboratory examination V72.6 SAR
1 YO / UA / NS
Incomplete abortion O03.4 • P/ dilation and curretage 2 FTA
• Consult to anesthesia 69.02 NS
department

• IVFD RL ftt xx/m

• Observation of Vital sign
C56.9 • Laboratory examination
Mrs. END / 53
Recurrent ovarian cancer + loss of
S06.0 • Consult to neurology V47.6
SAR
2 consciousness caused by intracranial metastatic department 2 FTA
YO / RA / IS SOL + Blepharoconjunctivitis OD H10.50 • Consult to IS
1 ophthalmology
department
• US Confirmation
OBSTETRIC
 Identity Mrs. FEB/ 36 YO / UA / NS
Chief complain Preterm pregnancy with abnormality of rhesus on mother

History Patient was referred by obstetrician and diagnosed with G2P1A0 29 weeks gestational age not inlabor with severe
anemia + prior CS 1x (o.i breech presenation + anhidramnion) + rhesus negative mother SLF cephalic presentasion for
blood transfusion. History of abdominal crump spread to waist and back (-) bloody show (-), amniotic discharge (-),
leuchorrhea (-), vaginal bleeding (-)
Patient admitted that her pregnancy was preterm and she can still felt the movement of the fetus.
Marital status 1x, 5 years
Reproduction status Menarche since 13 yo, regular cycle 28 days, for 5-7 days. LMP : 28– 12 - 2018
Obstetric history 1. 2015, boy, 3500 gram, CS o.i breech presentasion and anhidramnion, Bunda Hospital Palembang
2. This pregnancy

Physical examination BP : 110/60 mmHg, P : 80 x/min, T : 36.5 C, RR : 20 x/min, Weight 54 kg, Height 156 cm
Obstetrical examination Palpation :
IT3 Fundal height ½ umbilical-proc. xyphoideus (24 cm), superior, contraction (-), FHR 140x/m
VT:
Patient refused

US confirmation - Single life fetus cephalic presentation

- Fetal Biometry: BPD : 7.74 cm AC : 26.88 cm EFW 1615 g
HC : 28.87 cm FL. : 5.65 cm
- Placenta at anterior corpus
- Amniotic fluid was enough
- PI 0,79 RI 0,55
C/ 29 weeks gestational age SLF transverse lie
 Identity Mrs. FEB/ 36 YO / UA / NS
Diagnosis G2P1A0 29 weeks gestational age not inlabor with severe anemia + prior CS 1x (o.i breech presenation + anhidramnion)
+ rhesus negative mother SLF transverse lie
Therapy • Expectative management
• Observation of Vital sign, uterine contraction, FHR
• VFD RL gtt xx/min
• Laboratory examination
• Consult to dr. Putri Minarin SpOG (K)  refer ER consultant on duty (dr. H Iskandar Zulqarnain, SpOG (K))
• Consult to dr. H Iskandar Zulqarnain, SpOG (K)  refer to fetomaternal subdivision (dr. Nuswil B, SpOG (K))
• Consult to dr. Nuswil B, SpOG (K):
• Lung Maturation  inj. Dexamethasone 12 gr/ 24 hours
• Consult to hematology department
• PRC tranfusion until Hb 10gr/dL
GYNECOLOGY
 Identity Mrs. NEL / 38 YO / UA / NS
Chief complain Preterm pregnancy with vaginal bleeding

History 3 days before admission, patient complained vaginal bleeding, amount 4x change pads. abdominal crump (-). History
expulse tissue like chicken liver (+), expulse tissue like fish eye (-), of abdominal massage (-), post coital (-), leucorrhea
(-), history of trauma (-).
Patient admitted preterm pregnancy
Marital status 1x, 11 years
Reproduction status Menarche since 12 yo, regular cycle 28 days, for 5-7 days. LMP : 12– 04 - 2019
Medicine history Patient was referred from obstetrician

Physical examination BP : 120/60 mmHg, P : 80 x/min, T : 36.5 C, RR : 20 x/min

Obstetrical examination Palpation :
flat, supple, fundal height cant be measure, mass (-), tenderness (-), free fluig sign (-)
VT and inspeculo:
Patient refused

US confirmation - Uterine enlargement containt of complex mass suggestive a rest of conceptus

C/ rest of conceptus
Identity Mrs. NEL / 38 YO / UA / NS
Diagnosis Incomplete abortion
Therapy • Observation of Vital sign
• Laboratory examination
• P/ dilation and curretage
• Consult to anesthesia department
Mrs. NEL / 38 YO / UA / NS
Procedure Case Outcome
Dilation and Mrs. NEL / 38 YO / UA / NS 11.00 PM. Operation started
curretage Patient on litotomy position and on total intravenous anesthesia. Aseptic and
Preop diagnosis: antiseptic on vulva. Bladder emptying using catheter. Upper and lower sims
ICD 10 Incomplete abortion placed. Portio shown avoe. Portio was grasped with tenaculum on 11 o’clock
O03.4 direction. Uterus length was 7 cm. Curretage was performed obtaining tissue and
75 cc of blood. After making sure there was no tissue left, the tenaculum wa
removed
ICD 9-CM Post op diagnosis:
69.02 Post curretage o.i incomplete
abortion 14.30 PM. Operation over
OP :
NS/FTA
 Identity Mrs. END / 53 YO / RA / IS
Chief complain Malaise and loss of consciousness
History 2 days before admission, patient complained malaise. Nausea (-) vomit (-), loss of appetite (+), weoght loss (+). Patient
was diagnosed with ovarian cancer since 2015, had done chemotherapy 12 times, 1 series 6 times., and had done
radiotherapy 10 course. Patient on scheduled for 6th chemotherapy on July 19th, 2019

PA 743/A/2018  immunohistochemistry test GFAP, CK7, CK20.

PA 1022/A/2019  malignancy metastatic on peritoneum
Marital status 1x, 15 years
Reproduction status Menopause, 10th
Obstetric history P0A0
Physical examination BP : 110/70 mmHg, P : 80 x/min, T : 36.5 C, RR : 20 x/min. Weight 39 kg, height 145 cm
Obstetrical examination Palpation : flat, supple, mass (-), tenderness (-), free fluig sign (-)
VT: vaginal stump, mass (-)
Inspeculo: vaginal stump, mass (-)
US confirmation - Uterine and both of adnexa ~ HTSOB
- No abnormal mass on abdominal cavity and pelvic
- Solid mass on ovary, malignancy mass was suspected
- Liver in normal condition
- Right kidney hidronephrosis
- Left kidney normal
C/ recurrent ovarian malignancy
right kidney hydronephrosis
 Identity Mrs. END / 53 YO / RA / IS
Diagnosis Recurrent ovarian cancer + loss of consciousness caused by intracranial metastatic SOL + Blepharoconjunctivitis OD
Therapy • IVFD RL ftt xx/m
• Observation of Vital sign
• Laboratory examination
• Consult to neurology department
• Consult to ophthalmology department
• US Confirmation
Laboratory result Hb : 8.0 g/dL BSS : 116 mg/dL Bilirubin total : 1.10
July 18th, 2019 RBC : 3.02 X 106 /mm3 Ur : 45 SGOT: 14
WBC : 5.01 X 103/ mm3 Cr : 0.86 SGPT : 10
Ht : 23 % Ca : 9.0 Albumin : 3.2
RDW CV : 27.80 % Na : 137 AFP : 6.44
Mg : 1.60 CEA : 3.70
K : 3.2 CA 125 : 37.2
Cl : 99
Follow up
Neurology Department A/
July 18th, 2019 Obs. loss of consciousness caused by intracranial metastatic SOL
P/
• Inj dexamethasone 10 mg loading dose, continue with 4 x 5 mg iv
• Fenitoin continue
• Advise : joint care
 Identity Mrs. END / 53 YO / RA / IS
Ophthalmology A/
Department Blepharoconjunctivitis OD
July 18th, 2019
P/
• Hygiene, wash the eyelid using baby shampoo 2 times / day
• LFX ED gtt . 4 hours
• Cendo lyteers ED 1 gtt/ 4 hours
THANK YOU