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CASE
June 18th, 2012
IDENTITY
• Name : HSN
• POB, DOB : Malang, April 6th 1952
• Age : 60 years old
• Sex : Male
• Religion : Islam
• Nationality : Indonesia
• Occupation : Enterpreneur
• Address : Jl. Pulau Kawe Gg 52 Buntu No 4,
Denpasar Selatan
• TOA : June 17th 2012 (06.06 pm)
ANAMNESIS
Chief Complaint : Nausea
Abdomen
I distention (-)
Aus bowel sound (+) N
Per timpani (+),
Palp tenderness (+) epigastrium, hepatomegaly (-),
splenomegaly (-)
Extremities
Sianosis (-/-), warm (+/+), edema (-/-) CRT <2”
(-/-) (+/+) (-/-)
Laboratory Findings
CBC (June 14th 2012 06.35 pm)
No Parameter Result Unit Range Remarks
1 WBC 8,27 X103 u/L 4,1-11,0 Normal
Neu 12,90 X103 u/L 2,50-7,50 Normal
Lym 1,30 X103 u/L 1,00-4,00 Normal
Mono 0,50 X103 u/L 0,10-1,20 Normal
Eos 0,60 X103 u/L 0,00-0,50 Normal
Baso 0,10 X103 u/L 0,00-0,10 Normal
2 RBC 5,11 X106 u/L 4,00-5,20 Normal
3 HGB 14,10 g/dL 12,00-16,00 Normal
4 HCT 40,90 % 41,00-53,00 Low
5 MCV 81,90 fL 80,00-100,00 Normal
6 MCH 27,30 Pg 26,00-34,00 Normal
7 PLT 244,70 X103 u/L 140,00-440,00 Normal
Laboratory Findings
Blood Chemistry (June 14th 2012 06.35 pm)
No Parameter Result Unit Range Remarks
1 AST 22,10 U/L 11,00-33,00 Normal
2 ALT 21,20 U/L 11,00-50,00 Normal
3 Albumin 3,50 g/dl 3,40-4,80 Normal
4 BUN 4,00 mg/dl 8,00-23,00 Low
5 Creatinin 0,79 Mg/dl 0,70-1,20 Normal
6 Randon Blood 156,00 Mg/dl 70,00-140,00 High
Sugar
6 Na 141,00 mmol/L 136,00-145,00 Normal
7 K 2,4 mmol/L 3,50-5,10 Low
Assessment
Diabetes Melitus type 2 + gastropati Diabeticum+
Hipertension stage 1
Planning
THERAPY
Monitoring
Vital Sign
Improvement of symptoms
Diagnostic
Endoscopy
THANK YOU