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  • Night Shift Report: Emergency Room

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    Geraldi Ayub Fujiwan Tombe
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    Mrs. SJ, a 31-year-old pregnant woman, presented to the emergency room with contractions and bloody show. She was 41 weeks pregnant with her second child. On examination, she was in active labor with a single living fetus in head presentation. She was diagnosed with pregnancy at 41 weeks inpartu kala I. She received IV fluids and monitoring as she was in active labor.

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    Mrs. SJ, a 31-year-old pregnant woman, presented to the emergency room with contractions and bloody show. She was 41 weeks pregnant with her second child. On examination, she was in active labor with a single living fetus in head presentation. She was diagnosed with pregnancy at 41 weeks inpartu kala I. She received IV fluids and monitoring as she was in active labor.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as PPTX, PDF, TXT or read online from Scribd
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    7 views9 pages

    Night Shift Report: Emergency Room

    Uploaded by

    Geraldi Ayub Fujiwan Tombe
    Mrs. SJ, a 31-year-old pregnant woman, presented to the emergency room with contractions and bloody show. She was 41 weeks pregnant with her second child. On examination, she was in active labor with a single living fetus in head presentation. She was diagnosed with pregnancy at 41 weeks inpartu kala I. She received IV fluids and monitoring as she was in active labor.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as PPTX, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    of 9

    Emergency Room

    Night Shift Report


    May 27th 2013

    2. Mrs. SJ (31 YO)

    Chief complaint contraction Additional complaint

    : stomach

    : bloody Show

    History of illness : ( Autoanamnesis ) 1 days before admittance, patient G2P1A0 felt stomach contraction, and it getting worst day by day. The First day of last period was august 15th, 2013. The bloody show came out since yesterday night. Amniotic fluid (-).

    General Examination BP : 120/70mmHg HR : 84x/m RR : 23x/m T : 36,2C Head : Bruise (-), hematom (-), tumor (-), blood (-) Eyes : Pupil round, isochoric 3mm/3mm, centered, Direct Light Reflex +/+, Indirect Light Reflex+/+, anemic conjungtival -/-, icteric sclerae -/-

    Extremity cap. refill < 2, warm extremities, edema (-),

    Status Obstetrik
    Abdomen Ins : Pregnant, hematom (-), bruise (-) Pal : smooth, H/L not palpable, tenderness (-), defence muscular(-) L1 : bottom presentation L2 : Right back presentation L3 : Head presentation L4 : ready in the pelvic His : 1x/menit. Relaxation (+)

    Vaginal toucher
    Calm, Mass (-) Portio : axis medial, soft concistency, dilatation portio cm, efficement 50%.

    DIAGNOSIS

    G2P1A0 Pregnancy 41 weeks inpartu kala I, active phase, fetus, single, life, head presentation

    TREATMENT

    IVFD : RL 20 drop/min

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