Case RSUD Syamsudin SH
Transcript of 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