Laporan Kasus

Bagian Ilmu Penyakit DalamUniversitas Kristen Indonesia

05 Juni 2014Kelompok 1

Ny. Surta Hutahaean, 54 Tahun Saturday, May 24th 2014, 17:13:51 PM

Findings Assesment Therapy PlanningLemas.Mual (+)Muntah (+)Penurunan nafsu makanNyri ulu hati (+).PHYSICAL EXAMINATION Appearance : being sickGCS : E4V5M6Awareness: Composmentis, BP : 120/80 mmHg, HR : 70x/min,RR : 24x/min, T : 36°CHead: Normocephaly Eye : pale conjunctiva -/-, icteric sclera -/- THT : normal Mouth : normalNeck : lymph nodes not enlarge, JVP : 5-2 cmH2O

Thorax Ins : symmetric Pal : vocal fremitus sound symmetric Per : sonor right = leftAus : basic sound of breath vesicular, wheezing (-/-), ronchi (-/-)Heart : Heart sound I & II regular, murmur (-), gallop (-)

Dyspepsia Difficult intake

Pro Hospitalized Diet : soft diet unstimulateIVFD : III RL / 24 hourMm/•Omeprazole 2x40 mg (IV)•Ondancetron 2x4 mg (IV)•Sucralfat Cyr 3X1C

Check LabH2TL & Complete urine

in the room

Mrs. Surta Hutahaean, 54 years

Saturday, May 24th 2014, 17:13:51 PM

Findings Assesment Therapy PlanningAbdominal Ins : flat Aus : bowel sound 5x/minPer : timpani, percution pain (-)Pal : supel, tenderness in the epigastric (+) and suprapubic (+)

Extremitieswarm acral, CRT < 2 s”, edema -/-

LAB FINDING -H2TL:Hemoglobin : 11,1 g/dl Haematocrite : 31,5 % Leucocyte: 6.400 /ul Thrombocyte : 129 .000 /ul

- Casual Plasma Glucose: 78 mg/dl

-ELECTROLYTENatrium : 145 mmol/LKalium : 3,8 mmol/LClorida : 105 mmol/L

Dyspepsia Difficult intake

Pro Hospitalized Diet : soft diet unstimulateIVFD : III RL / 24 hourMm/•Omeprazole 2x40 mg (IV)•Ondancetron 2x4 mg (IV)•Sucralfat Cyr 3X1C

Check Lab H2TL & Complete

urine in the room

Name : Mrs. Surta Hutahaean TC : Thursday, June 05th 2014CC : Limp

Subjective Data

Main symptom : LimpAdditional symptom : Nausea, vomitus , decreased appetite,

epigastric pain.

Patient came to UKI’s hospital with limp about 1 mounth with nausea and vomite about 3 times per day, vomite is white fluid, patient also complain decreased appetite, epigastric pain about 1 week ago. The patient eats 2 times per day just a little food and mineral water. The patient has gone to the clinic for treatment , and get the medicines (omeprazole) but the symptom is not healed. For the defecate and urinate are no complaints. The patient have a history illness is gastritic.

Anamnesis

Past Medical History and Treatment gastritic

Family HistoryDenied

Social HistoryDenied

Appearance : being sick GCS E4M6V5 Awareness : composmentis BP : 120/80 mmHg RR: 24x/minute T : 36°C HR : 70x/minute Eyes: Pale conjunctiva (-/-) , sclera icteric -/- Ears, Nose, Throat : normalMouth : normalNeck : lymph nodes not enlargeJVP : normal

Objective Data

Thorax Ins : symmetric Pal : vocal fremitus sound symmetric Per : sonor right = leftAus : basic sound of breath vesicular, wheezing (-/-), ronchi (-/-)

Heart : Heart sound I & II regular, murmur (-), gallop (-)

Abdominal Ins : flat Aus : bowel sound 6x/minPer : no percution pain, timpanyPal : supel, tenderness of epigastric (+) and suprapubic (+)

Extremitieswarm acral, CRT < 2 s”, edema -/-

H2TL : Hemoglobin : 11,1 g/dl Haematocrite : 31,5 % Leucocyte: 6.400 /ul Thrombocyte : 129 .000 /ul

- Casual Plasma Glucose: 78 mg/dl

-ELECTROLYTE Natrium : 145 mmol/L Kalium : 3,8 mmol/L Clorida : 105 mmol/L

Clinical Laboratory

Assessment

DyspepsiaDifficult intake

Pro Hospitalized Diet : soft diet unstimulate IVFD : III RL / 24 hourMm/ •Omeprazole 2x40 mg (IV) •Ondancetron 2x4 mg (IV) •Sucralfat Cyr 3X1C

Therapy

Laboratorium Blood H2TL & Complete Urine in the room

Planning

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