You are on page 1of 12

Department of Internal Medicine Christian University of Indonesia

December 7th 2013

Mrs. Saomi, 68 YO

CC : Epigastric pain

TC : Saturday/7 Desember 2013/7.30 AM CM : 71-72-03-00

Epigastric pain Nausea Vomite Diarrhea

Gastoenteritis Acute Moderate Dehidration

Hospitalization IVFD : III RL / 24 h Diit : porigd

Hematology -Electrolyte -Gastroscopy feses

Appearance: moderate illness, GCS : E4V5M6, BP: 140/70 mmHg, PR : 108 x/min (adequate,regular) RR : 22 x/min, T: 36,5C Eye : conjunctiva anemia -/- sclera icteric -/Ear nose throat : normal Neck : lymph nodes not enlarged JVP : increased (5-2 cmH20)

Mm/ Ranitidine HCl IV 2x50 mg Ondancentron IV 2x40 mg Sucralfat syr 3x2 C Zinc 3x1

Inspection : symmetric Palpation : vocal fremitus symmetric Percussion : symmetric, sonor sound Auscultation : vesiculer rhonki -/- , whezing -/- Heart Sound S1 S2 Normal, murmur ( ), gallop ( ) Abdominal Inspection : abdomen looks flat Palpation : Pressure pain (+) Epigastric Percussion : Tympani Auscultation : bowel sounds (+) 8x/minute Extremitas : warm acral, CR<2, pitting edema -/- , Turgor LAB FINDING : Na : 143 mmol/L , K : 3.9 mmol/L , Cl : 108 mmlo/L

Subjective Data
Name Address CM TC CC : Mrs. Saomi : Bekasi : 71-72-03-00 : Saturday/ December 7th 2013/ 7.30 AM : Epigastric Pain

Main symptom : Epigastric Pain Additional symptom : Nausea, Vomiting, Diarrhea 68 years old female patient come to the emergency with complaints of epigastric pain since 5 hours before hospital admission. Epigastric pain is like kneaded. Epigastric pain occurs continously. Before the epigastric pain occurs, she ate food from her neighbour. After she ate the fod, she felt epigastric pain and had diarrhea as many as 4 times. The feses is like a water, no blood, no mucus. She didnt eat or drink medicine to reduce the epigastric pain. The other symptoms were nausea, vomited, diarrhea, malaise, and lost of appetite. Patient had a history of hypertension since 1 year ago and she never controlled it. Patient consumed Captopril. Patient had allergy of chicken, prawn, and egg.

Past Medical History and Treatment

Hypertension (+) 1 year ago use Captopril as the medicine, Diabetes Meillitus (-),

Family History

Social History
Smoking (-), Alcohol (-)

Objective Data
Consciousness Appearance Blood Pressure Pulse Rate Respiration Rate Temperature EYE Ear Nose Throat Lips Mucose Neck JVP THORAX : Heart Inspection Palpation Percussion : : : : : : : : : : : E4V5M6 ; Composmentis moderate ill 140/70 mmHg 108 x/min (adequate,regular) 22 x/min 36,50C conjungtiva anemic -/- ; sclera icteric -/Normal dry Normal Normal (5-2 cmH20)

: Ictus Cordis invisible : IC not palpable : Right heart border Inter Costae IV line Parasternal dextra, Left heart border Inter Costae V mid clavicula sinistra Auscultation : S1 single, S2 single, regular, murmur (-) gallop (-)

Objective Data
Pulmo Inspection Palpation Percussion Auscultation ABDOMEN Inspection Auscultation Palpation : : : : Static and dynamic symmetric Vocal Fremitus right and left symmetric Sonor symmetric Vesiculer, wheezing -/-, ronkhi +/+

Percussion EXTREMITIE Pitting Edema (-/-) in lower extremity; warm (-) ; CRT <2 second Tofus in pedis dextra. SKIN Turgor : decreased

: stomach looks flat : Bowel sound (+), 8 x/min : Defense muscular Pressure pain in epigastrium + LiverSpleen impalpable ; : Tympani; Percussion Pain

Labolatorium Test
Na 143 mmol/L K 3,9 mmol/L Cl 108 mmol/L

Acute Gastroenteritis with Moderate Dehydration Hypertension gr I

Pro Hospitalized IVFD : III RL / 24 hours Diit : non-stimulating rice porridge Mm/ Ranitidin 2x1 amp Ondancentron 2x4mg ( bolus IV ) Sucralfat syrup 3x2 C a.c. Zink kid 3x1 tab

Rehidration Feces Cultur H2TL test

Department of Internal Medicine Christian University of Indonesia

Thank You
December, 7th 2013