REFKAS

Intan Tsaqif Farah Fortuna - 30101700077

Pembimbing Klinik : dr. Lusito, Sp. PD

 Patient’s Identity
• Name : Mrs. N
• Age : 30 y.o
• Gender : Female
• Religion : Islam
• Occupation : Housewife
• Address : Genuk
• No. RM : 01-08-xxxx
• Room : Izzah 1
• Entry Date : 14 Oct 2021 (Thursday)
• Payment by : BPJS non PBI
History Taking
Chief Complain Epigastric pain and headache

History of Present Illness

Patient went to Sultan Agung Islamic Hospital on October 14, 2021. She complained of
pain in epigatrium and headache since the beginning of the year and getting worse since
1 week ago. The symptoms occurred all the time even when she was resting so that it
interferes the patient's daily activities. In addition, she also complained of nausea, yellow
vomiting, increased pain after eating, burning sensation in the throat, mouth feels sour
and bitter, pain in the left waist.
History Taking
Additional
Information
Patient had a history of gastric lavage in 2010 due to vomiting
blood and dark stools.

Patient admits that she often takes headache relievers and

eats late or eats irregularly
History Taking
History of Family History of
Previous Illness Genetic Related Disease
Same illness (Yes) (No)
Hypertension (No) (No)
DM (No) (Yes)
Cholesterol (No) (No)
Heart Disease (No) (No)
Kidney disease (No) (No)
 Physical
Examination
General Condition Looks sick

Awareness Composmentis (GCS = 15)

Vital Sign Blood pressure 114/72 mmHg

Pulse 85x/min
Breath freq. 22x/min
Temperature 36 C
SpO2 100%

BMI Body Weight 60 kg

Body height 158 cm
BMI 24 kg/m2
 Skin Icteric (-), Cyanosis (-), Pruritus (-), Wound (-)
Head Mesocephalic, Pain on palpation (-)
Eyes Anemic conjunctiva (-/-), icteric sclera (-/-), sunken eyes
(-/-), pupillary reflex (+/+)

Nose Discharge (-/-), nasal flaring (-)

Ears Discharge (-/-), hearing impairment (-/-)
Mouth Cyanosis (-), tongue deviation (-)
Neck Mass (-), Lymph hypertrophy (-), trachea deviation (-),
jugular vein distention (-), thyroid enlargement (-)
Thorax Examination Within Normal Limits

Anterior Posterior

RR 20 x/min, Thoracal breathing, pectus

RR 20 x/min, Hyperpigmentation (-) Wound (-),
Statis excavatum / carinatum (-), Hyperpigmentation
sikatrik (-), striae (-), Hemithorax D=S, Diameter AP
Inspection (-) Wound (-), sikatrik (-), striae (-), spider nevi (-),
< LL
Hemithorax D=S, Diameter AP < LL

Dynamic Movement of hemithorax D=S. Retraction of Movement of hemithorax D=S. Retraction of

Inspection accessory breathing muscle(-) accessory breathing muscle(-)

Pain (-), mass (-), enlargement of ICS (-), Stem Pain (-), mass (-), enlargement of ICS (-), Stem
Palpation
fremitus (+) fremitus (+)

Percussion Sonor (+) Dullness on the base (-) Sonor (+)

Auscultation Vesicular (+), Wheezing (-), Ronchi (-) Vesicular (+), Wheezing (-), Ronchi (-)
Cardiac
Within Normal Limits
Examination
Inspection Ictus cordis unseen

Ictus cordis palpable at ICS V midclavicular line, thrill (-), pulsus

Palpation
epigastrium (-), pulsus parasternal (-), sternal lift (-)

- Upper border ICS II left sternal line

- Waist of heart ICS III left parasternal line

Percussion
- Right border ICS V right sternal line

- Left border ICS V left midclavicular line 2 cm to medial

- Aorta valve S1 & S2 pure

- Pulmonal valve S1 & S2 pure

Auscultation
- Tricuspid valve S1 & S2 pure

- Mitral valve S1 & S2 pure

Extremity Examination Within Normal Limits

  Superior Inferior

Oedema -/- -/-

Cold -/- -/-

Cyanosis -/- -/-

A. Radialis A. Dorsalis pedis

Distal Pulsation
+/+ +/+

Capillary Refill Time <2s <2s

Clubbing Finger -/- -/-

Ulcer -/- -/-

 Supportive
Examination
EKG – 14/10/21 – 22.29 WIB

75x/min
Normo sinus rhythm with iverted T in V1
 Lab
Date 14/10/21 16/10/21
Examination Result Result Normal range
Haemoglobin 11 (L) 10.9 (L) 13.2 – 17.3 g/dL

Hematocrit 33.2 32.3 (L) 33 – 45 %

Leukocytes 7.95 6.01 3.80 – 10.60 x 103 /mm3
Thrombocyte 299 254 150 – 440 x 103 /mm3

GDS 66 (L) 75 – 110 mg/dL

Anti Dengue Ig G + -
Anti Dengue IgM - -
Interpretation Anemia, Anemia, low
hypoglycemia hematocrit
Data Abnormality
and Problem List
 Data Abnormality
History Taking
6. Often takes headache relievers
1. Pain in epigastrium (recurring
and eats late or eats irregularly
for about 10 months)
2. Headahce (getting worse since
1 week ago)
3. Nausea and yellow vomiting Abdomen Examination
4. Increased pain after eating, 1. Epigastric and left lumbal pain in
burning sensation in the palpation
throat, mouth feels sour and
bitter Supportive Examination
5. Pain in the left waist
6. History of gastric lavage in 1. Anemia
2010 due to vomiting blood and 2. Low hematocrit
dark stools
3. Hypoglycemia
 PROBLEM LIST

EPIGASTRI
01 C PAIN 02 ANEMIA

HYPOGLYCE
03 MIA
 EPIGASTRIC PAIN
Assessment Ip. Mx :
• DD : Organic / Functional Dyspepsia, General state
GERD Vital sign
• Alarm symptom
  Ip. Ex :
Ip. Dx : • Explain to the patient about the patient's
Blood routine, Endoscopy, PPI test, GERD disease, causes, and complications
Q, USG, Urea Breath Test • Education to avoid food or drinks such as tea,
chocolate, coffee, orange juice, chili peppers,
Ip.Tx : peppermint and soft drinks  stimulates acid
Ondancetron 4 mg 3x1 secretion
Omeprazol 20 mg 1x1 • Education to stop smoking and avoid alcohol
Sucralfat syr 3x1 consumption  affects epithelial cells and
reduces LES tone
 ANEMIA
Assessment : IP. Tx :
Sign of anemia • Paracetamol 500 mg 3x1
Types of anemia: • Ferro sulfat 200 mg 3x1
- anemia microcytic hypochromic • Vitamin C 500mg 1x1
- anemia normocytic normochromic
- anemia microcytic IP. Mx :
• General state
IP. Dx : • Vital sign
Complete Blood Test • Blood routine
Iron Panel (iron serum, ferritin, TIBC,
transferrin) IP. Ex :
• Explain about anemia and the necessary therapy
• Bedrest
• Diet high in iron: meat, fish, green vegetables, beans,
potatoes
 HYPOGLYCEMIA
Assessment
-
Ip. Mx :
• Random blood glucose 15 min after
Ip. Dx :
therapy
Random blood glucose
Ip. Ex :
Ip. Tx :
Education to maintain adequate food intake
• Glucose 15-20 g (2-3 tablespoons sugar) in water
THANK
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 MONTHLY CONCEPTS
PLUTO MARS VENUS MARS JUPITER SATURN
It’s considered a Mars is a very cold Venus has a Mars is a very cold Jupiter is the Saturn has several
dwarf planet place beautiful name place biggest planet rings

MA AP MA
JAN FEB JUN
AU R R
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NO DE
JUL SEP
G T V C
MARS VENUS EARTH JUPITER SATURN PLUTO
Mars is a very cold Venus is the second Earth is where we Jupiter is the Saturn has several It’s considered a
place planet all live on biggest planet rings dwarf planet
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Saturn has several It’s considered a dwarf
rings planet

Venus is the second Mars is a very cold

planet JUN JUL place
MAY AUG
Jupiter is the biggest Venus has a beautiful
APR SEP
planet name
6 7
Venus has a beautiful 5 8 Jupiter is the biggest
MAR 4 9 OCT
name planet

Mars is a very cold

3 10 Venus is the second
FEB NOV
place 2 11 planet

It’s considered a dwarf Saturn has several

JAN 1 12 DEC
planet rings
 MEDICAL INFOGRAPHIC
MARS VENUS
Mars is actually a cold Venus is the second
place planet

PLUTO JUPITER
It’s considered a dwarf Jupiter is the biggest
planet planet
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JA FE MA AP MA JU AU OC NO DE
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N B R R Y N G T V C

MARS SATURN VENUS JUPITER

Mars is a very cold Saturn is the ringed Venus is the second Jupiter is the
place planet planet biggest planet
 MEDICAL INFOGRAPHIC
MERCURY MARS
It’s the closest planet to 01 04 Mars is actually a very
the Sun cold place

JUPITER NEPTUNE
Jupiter is the biggest 02 05 Neptune is very far
planet away from us

VENUS SATURN
Venus is the second 03 06 Saturn is the ringed
planet planet
 THIS IS A TIMELINE

MERCUR NEPTUN
VENUS
Y
Mercury is a small
E
Neptune is very far Venus is the second
planet away planet
JUPITER MARS
Jupiter is the Mars is a very cold
biggest planet place
 THIS IS A TABLE
JAN FEB MAR APR MAY JUN
Venus is the It’s the farthest Despite being Mercury is the Venus is the It’s the farthest
second planet planet from the red, Mars is a closest planet second planet planet from the
from the Sun Sun cold place to the Sun from the Sun Sun

JUL AUG SEP OCT NOV DEC

It’s the farthest Venus is the Mercury is the Despite being It’s the farthest Venus is the
planet from the second planet closest planet red, Mars is a planet from the second planet
Sun from the Sun to the Sun cold place Sun from the Sun
 IMPORTANT DATES
M Tu W Th F Sa Su
1 2 3 4 5
NEPTUNE
Neptune is the farthest planet
6 7 8 9 10 11 12 from the Sun

13 14 15 16 17 18 19
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20 21 22 23 24 25 25
Mercury is the closest planet to
the Sun
26 27 28 29 30
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It’s the closest planet to the It’s the closest planet to the
Sun 01 07 Sun

Venus is the second planet Venus is the second planet

from the Sun 02 08 from the Sun

Mars is actually a very cold Mars is actually a very cold

place 03 09 place

Jupiter is the biggest planet Jupiter is the biggest planet

of them all 04 10 of them all

It’s composed of hydrogen It’s composed of hydrogen

and helium 05 11 and helium

It’s the farthest planet from It’s the farthest planet from
the Sun 06 12 the Sun
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