case rsud syamsudin sh

8/7/2019 Case RSUD Syamsudin SH

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CASE PRESENTATION

OBSTETRICS & GYNECOLOGY

DEPARTMENTdr. Indra Utama Masyhur, Sp. OG

dr. Ismu Setyo Djatmiko, Sp. OG

dr. Hesty Duhita P, Sp. OG

Gunterus Evans

Jhonsen Indrawan

Dyana Suwandy

Sherly OliviantinPeter Mulyono Wijaya

R. Syamsudin, SH General District Hospital Sukabumi

Faculty of Medicine

Atma Jaya Catholic University of Indonesia

February 14, 2011 March 12, 2011


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Identity Name : Mrs. Y

Age : 29 years old

Religion : Moslem

Education : Elementary School

Occupation : House wife

Citizenship : Indonesia

Tribe : Sundanese

Address :Kp Warudoyong,

Sukabumi

1st time marria e, 10 ears


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Husband : Mr. S

Age : 33 years

Religion : Moslem Education : junior high school

Occupation : employee

Citizenship : Indonesia

Tribe : Sundanese

Address :Kp Warudoyong, Sukabumi city


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History taking

Chief Complaint : abdominal cramps 12 hours

before admission to hospital

12 hours before admission patient complained

of abdominal cramps, followed by bloody

show from vagina. 3 hours before admission

cramping became more often, occurred 2

times in 10 minutes and accompanied with

bloody show


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Other complaint :

Palpitation

Dizziness -

Epigastric pain

Vomiting -

Dyspneu

Vision


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Previous medical history :

Previous hypertension

Previous abortion -

History of infertility and medical treatment from doctor

(hormonal/IVF) -

History of STD -

History of Sterilization


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Gynecologic History

Period : 28 days, regular

Duration : 5 days

Volume : approx 60 cc/ day Menstrual Problem : dysmenorrhea -

Menarche : 12 y. o

Coitarche : 19 y.o (with herhusband)

Contraception: -


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Obstetrical History

G3P2A0

LMP : 15th February 2011

No. Husband Gestational

Age

Year Methods Attenda

nt

Complic

ation

Child

Sex

Child

Age

1. I 9 months 2002 SVD Midwife (-) Boy 8 yrs

2. I 9 months 2007 SVD Midwife (-) Girl 3 yrs

3. This one


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Present State

15th FEBRUARY 2011 General condition : in pain

Conciousness : compos mentis

Height : 155 cm

Weight : 60 kg

BP : 110/80

mmHg HR : 82

beats/ mnt

RR : 20


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Physical Examination

Head : normocephaly, deformity

Face : chloasma gravidarum +

Eyes : ananemic conjunctiva, anicteri c sclera

Neck : thyroid gland enlargement -, lymph

nodes enlargement -, mass

Heart and Lung wNL

Mammae : symmetrical, hyperpigmented

areola +/+


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Abdomen:

I : Striae gravidarum (+); striae nigra (-)

P: fundal height : 30 cm

Uterine contraction : (+)

1st Leoplod : buttock

2nd Leopold : right spine

3rd Leopold : head

4th Leopold : 2/5


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Extremity

Pitting edema -/-

Physiologic reflex +/+

Pathologic reflex -/-

Warm, capillary refill time< 2 sec, cyanosis -/-

Vaginal Toucher :

v/v normal, thick and stiff portio

10 cm dilatation, 100% effacement, amniotic sac (-)

Cephalic presentation; Hodge 3+; denominator : right anterior

minor fontanelle


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Additional examination

Hg = 10.8 gr/dL

Ht = 30.2%

WBCs = 10.800/L

Platelets = 257.000/ L

Bleeding time = 2

Clotting time = 4

RBG = 83 mg/dL

Blood type = B/ Rh +


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Resume

Patient - G3P2A0, 32 years old, in labor, GA 40

weeks (LMP), first stage latent phase with

severe preeclampsia

chief complaint : abdominal cramping 12

hours before the admission

Bloody show +

PE :

General condition : in pain

Conciousness : compos mentis

Hei ht : 155 cm


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Weight : 60 kg

BP : 110/80

mmHg HR : 82 beats/

mnt

RR : 20

times/mnt

Temperature : 37,0rC

Abdominal :

I : Striae gravidarum (+); striae nigra (-)

P: fundal height : 30 cm

Uterine contraction : (+)

Leoplod I : buttock

Leopold II: spine at right


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Vaginal Toucher :

v/v normal, thick and soft portio

10 cm dilatation, 100% effacement, amniotic sac (-)

Cephalic presentation; Hodge 3+; denominator : right anterior

minor fontanelle


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Hg = 10.8 gr/dL

Ht = 30.2%

WBCs = 10.800/L

Platelets = 257.000/ L

Bleeding time = 2

Clotting time = 4

RBG = 83 mg/dL

Blood type = B/ Rh +


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Working Diagnosis

Maternal Diagnosis

- G3P2A0, 29 years old, in labor, GA 40 weeks

Second StageFetal Diagnosis : single, live, intrauterine fetus

with cephalic presentation


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Therapy

Immediate delivery


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DISCUSSION


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Delay for Women Who Die in

Childbirth Experienced 1st Delay : deciding to seek care for an obs

complication (recognition, fear, cost)

2nd

delay : actually reaching the Care FaciltyTransport

3rd Delay : obtaining care in facility (poor staff,

repayment, difficulity of blood supply,

equipment, op. theatre


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Client Flow Analysis for EmOc

Purpose :

Gather info about care pregnant client w/

complication

Eliminate /reduce delays in receiving care

Aim quickly evaluate client


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Critical Steps in Caring

Arrival (T1)

eValuation (T2)

Initial treatment T30

Definitive (T4)

Monitoring and recovery

Info and conselling and discharge


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The Times

T1 and T2 < 15 min

T2 and T3 +- 30 min

T2 and T4 +- 2 h


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Definitive Treatment (T4)

SC Ev / EF

Hysterectomy

Laparoscopy

Uterine evacuation

Manual placenta removal

AB, oxy, methergin

Blood transfusion

IV fluid

Repair laceration

Observ


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Time Planning on OB/GYN

Admission -Diagnosis

Diagnosis Initial

Treatment

InitialTreatment -Definitivetherapy


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ER Management

Patient having labor and come to ER

Triage

1 person taking history, ask about herfinance planning, and tell admission

procedure to her family immediately

1 person do examination and observation

Call Delivery Room to transfer the patient


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ER Time Management

Patient come on 02:42:17

history taking, physical examination, tell her

family simultaneously finish on 02:43 oclock Patient do pay on her own money

Cervix dilatation reach 10 cm (immediately

transfer)

Administration finished on 02:44:07

Arrived at Delivery room on 02:55 oclock

Time 13 minutes


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DR Time Management

02.45 Prepare room and Labor set

02.55 Patient come to VK Room

02.55 03.00 Taking history, Examinationmother-child and Vaginal Toucher

03.00 03.15 Patient was led to strained

simultaneously with uterine contraction

Oxytocin in RL 500 ml, 8 gtt per minutes


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DR Time Management

03.15 Childs Labor

Immediately check the baby and do early

breastfeeding

03.18 Placental Delivery

Ergonometrin 0.2 mg

Examine the placenta

03.20-03.25 Placental, vulva, vagina, cervix,

uterine and haemmorhage examination


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DR Time Management

03.25-03.40 suture

Lidocaine

03.40 05.40 Observation in Delivery roombefore transfer to MM Ward

- Antibiotics and pain management after labor

amoxicilline and mefenamic acid

- Clean Equipment and Room

- Check used items

- Management medical waste (yellow bag)


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Ward Management

05.30 prepare room

05.40 Cross checking in ward

06.00 SOAP by trainee09.00 Visite

Recheck planning for today


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Ward Management

16/02/2011

06.00 SOAP by Co Ass

09.00 VisiteNo pathologic problem occur

Patient can be released

09.00-09.30 administration finished thecalculation, patients family get the bill and

pay on cashier, after that, patient get released


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Wards Management

11.00 Resume was finished

Medical Record can be transfer to Medical

Record Central


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THANK YOU

case rsud syamsudin sh

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