OBSTETRIC EMERGENCY ROOM REPORT

DUTY ON : WEDNESDAY, FEBRUARY 14th 2019

4.PEB, 24 yo RYE
N ASSESS PROBLE ICD PLAN OF
DATA BASED
0 MENT M LIST X CARE
1 Anamnesis (ICD IX 89.03) :
Patient Referred from Bhakti Rahayu Hospital with G1P0000 38-39
Weeks, Single/IUFD, Transverse Position, Asthma Bronchiale, Mild
Anemia, Thrombocytopenia + Fever (Susp Dengue Hemorragic Fever)
Patient complained doesn’t feel fetal movement since 10.00 pm
(13/02/19), labor pain (-), watery vaginal discharge (-). Known
Transverse position since GA 38-39 weeks while PNC at O&G

Chronology :
11.00 am : Patient came to “Rumah Bersalin Bunda Setia” for PNC and
complained dyspnea
12.00 pm : Patient referred to Bhakti Rahayu Hospital and gave 1st
Nebulization
09.30 pm : Got the 2nd Nebulization
10.00 pm : FHB not found
11.45 pm : USG (TAS)  FHB (-)
01.30 am : Patient referred to Sanglah General Hospital
02.11 am : Patient arrived to Sanglah General Hospital

LMP : Forgotten
EDD : 21/02/19 (USG at 29-30 Weeks)
PNC : Midwife and O&G

Obstetric history :
1. Current pregnancy

Married: 1x ~ 1 year
 OBSTETRIC EMERGENCY ROOM REPORT
DUTY ON : WEDNESDAY, FEBRUARY 14th 2019
4.PEB, 24 yo RYE

N ASSESS PROBLE ICD PLAN OF

DATA BASED
0 MENT M LIST X CARE
2 Physical Examination (ICD IX 89.7) :
Weight/Height : 58/147
Present state :
GCS: E4V5M6 VAS : 2
BP : 120/80 RR : 20 SpO2: 99%
P : 82 Tax : 37.0
General state :
Eyes : Anemic (-)
Thorax : Cor : S1S2 single, regular, murmur (-)
Pulmo: Vesicular +/+, rhonchi+/+, wheezing -/-
Abdomen : ~ Obstetric state
Extremities: Warm +/+
+/+
Obstetric state :
Abdomen :
Leopold Examination:
L I : Palpable soft rounded part, seems buttock
L II : Palpable flat part, extended along right side, seems back
L III : Palpable hard rounded part, seems head
L IV : Convergent
Fundal Height 4 fingers below processus xyphoideus (32cm)
Uterine contraction (+) 2-3x/10’
FHB (-)
VT (RYE): 03.00 am : Cervical dilatation 2cm, eff 25%, membrane
(+), felt small parts, seems extremities
 OBSTETRIC EMERGENCY ROOM REPORT
DUTY ON : WEDNESDAY, FEBRUARY 14th 2019
4.PEB, 24 yo RYE
N ASSESS PROBLEM ICD
DATA BASED PLAN OF CARE
0 MENT LIST IX
3 USG TAS (ICD IX 88.78) : G1P0000 39 1.Aterm 06 Intervention :
Fetus, Single/IUFD, Transverse 1. Emergency CS
Weeks 0 Day, pregnancy 0 2. Joint Care with Internal
Presentation, FHB (-), FM (-) Medicine and Pulmonary
Biometry : Single/IUFD, with IUFD, Departement
BPD 10.01~36W1D AVE 35W3D Transverse Transverse
HC 33.7~37W6D EDD 18/03/19 Position, presentation Target :
1. Born Baby, and Mother in
AC 28.9~32W6D EFW 3001 gr Asthma 2. Asthma good condition
FL 6.9~35W5D Bronchiale, Obs Bronchiale 2. Optimal Care
Placenta fundus corpus anterior
grade II Fever Day – 1,
1st Stage of Instruction :
SDP : 2.6 cm Pdx : -
Labor Therapy :
4 Laboratory Result (ICD IX 99.07)
WBC 5.90 Emergency CS
EFW : 3001gr ↓
HGB 10.31 At 09.27 pm
HCT 34.76 born baby ♀,
PLT 181.50 2550 gr, AS : 7-8
SGOT/SGPT 25.4/ 21.00
BUN/SC 4.00/ 0.56
Alb/BS 3.46 / 101
PPT/INR/APTT 12.1/0.95/35.6