MORNIN

G
REPORT 08 Juli 2021
Pembimbing : dr. Andrianto Wisnu Nugroho, Sp. OT
IDENTITAS

• Nama : Ny. Fitrianingsih

• Usia 02
: 28 tahun 03
• Jenis kelamin : Perempuan
• No. RM : 1606****
• Alamat : Batu
• Pekerjaan : Wiraswasta
 ANAMNESIS
• Chief Complaint: Right Flank Pain
• History of current symptom:
Female 28 y.o came to the E.R 4 days ago with chief complaint right flank pain since 1 day before admitting to the hospital. Pain felt from
the back and stabbing to the mid-upper part of the stomach. Pain profile is gradualy worsing with the time and change of body position
especially bowing position with vas score (6-7). Nausea following with vomiting found to be sign of the onset of the chief complaint.
Nausea complaint didn’t triggered by position or smell. Vomiting profile come with yellowish liquid with mucousy thick consistency
around ¼ glass volume. Defecation disorder is denied, patient defecation 1 time/ day with mushy consistency of feces and yellow colour.
Urination disorder also denied, patient urin profile is clear with appropriate volume depending on drinking volume. History of fever, chest
pain, heart burn, and difficulty of breath is denied. History of longterm alcohol consumption is denied. Patient than being treated by
Internal Department as primary caretaker with diagnose abdominal pain and hypocalemia. 2 days being treated with no sign of
improvement, patient than being examined with usg abdoment with result :
1. Hepatomegaly non-specific
2. Free fluid loculated peripancreas with hiperdens echo
3. Multiple gallstones
Patient than consulted to the surgery department for follow-up treatment.
 ANAMNESIS

• History of past illness : Patient admitted to the hospital 2 month before with the diagnosis cholelithiasis
and gastritis.
• History of family illness : (-)
• History of medication : UDCA and Lansoprazole p.o, 3 month before with regular consumption
 Physical Examination Pulmo:
Jejas (-), Symetrical chest expanding (+), retraksi (-)
VES +/+ rhonki (-) wheezing (-)
+ + - - - -
+ + - - - -
TTV + + - - - -
GCS: 456
TD : 113/89 mmHg
HR : 63x/menit ABDOMEN:
RR: 18x/menit Inspection : distended, jejas (-)
SpO2 : 98% on room air Auscultation : bising usus (+) (18x /’)
Perkution : timpani, CVA pain (-)
K/L: Palpation : soefl, tenderness
Inspeksi: a/i/c/d -/-/-/-, RC +/+, PBI 3mm|3mm,
+ + -
Lip mucose (moist), Tonsil T1/T1, coated tongue Hepar : liver span +- 9 cm
(-), Oral mucose lesion (-), tonsil detritus (-), Lien : schufnerr 0, hacket 0 - + -
Lymph node enlargement (-). Murphy sign (+) - - -
THORAX:
Lesion (-)
Cor
Ictus cordis at ICS V MCL sinistra,
S1 S2 single reguler, murmur (-), gallop (-)
 Physical Examination
Ektremitas : warm, CRT <2s,   edema , skin turgor <2
det, palmar eritema (-/-), ptekie (-), purpura (-)

Genetalia : patient doesn’t consent to evaluate

Rektum : patient doesn’t consent to evaluate

Neurologis :
RCL | RCTL [+|+]
Motorik extremitas
lateralisasi (-)
Physiologic Reflex B|T|K|A : +2|+2|+2|+2
Patological Reflex H|G|S : -|-|-
 Supportive Assesment
Laboratorium: KIMIA DARAH
Hematologi Lengkap Bilirubin Direct : 0.37 (H)
HGB: 11,0 g/dl (L) Elektrolit
RBC: 5,81x 10^6 /uL (H) K+: 2,46 mmol/L (LL)
HCT: 34,4% (L)
 
MCV: 59,0 fL (L)
IMUNOLOGI
MCH: 18,9 pg (L)
Rapid Tes Ag Covid: Negatif
MCHC: 32,1 g/dl (H)

RDW-CV: 19,6% (H)

WBC: 6,24 x 10^3/uL (H)

Hitung Jenis

Eosinofil: 0,6% (L)

Neutrofil: 71,9% (H)

Limfosit: 21,2% (L)

Monosit: 6,1% (L)

PLT: 305 x 10^3/uL (L)

Conclusion : Cor and Pulmo in normal range

Problem List Working Diagnose Planning Diagnose Planning Therapy Planning
Monitoring

Abdominal pain regio Kolelitiasis a. CT-Scan Abdomen Injeksi metamizole Evaluasi keluhan
Hipocondrium   b. c. Profil Lipid 3x1 gram IV abdominal pain
c. USG Abdomen PO UDCA 3x1 tab
Dextra, Epigastrium   DL
Dextra, Umbilical   ERCP Bilirubin Total, Direk,
  a. Serum Amilase   Indirek
With differential b. Serum Lipase   SGOT SGPT
diagnose : c. CT-Scan Abdomen  
  d. ERCP  
e. MRI Pankreas Injeksi ceftriaxon 2x1
1. Susp. Mild-Acute f. Bilirubin Total, Direk,
Pancreatitis gram IV
Indirek
2. Susp. Colangitis

Hypocalemic Hipokalemia ec GI a. Blood electrolyte Drip KCl 25 mEq Serum Elektrolit Post
Loss dalam 500 cc NS 16 Koreksi
tpm mikro habis
dalam 12 jam (2
flash)