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Main Problem complain about her abdominal pain. Its started since a
month ago. abdominal pain is felt in the epigastric region.
The abdominal pain increases when the patient inhales. This
pain often felt periodically. Nausea and vomiting also
DM history (-)
GENERAL STATUS
BMI (Body Mass Indeks)
Weight : 65 kg BMI= 65: (1,65 x 1,65) = 23,87 kg/m2
High : 165 cm
Interpretation :
Normoweight
General :
Awareness : Fully Aware / Compos Mentis (GCS=15)
Vital Sign
Blood Pressure : 110/60 mmHg
Heart rate : 90 x/minute
Breath Frequency : 24 x/minute
Temp : 36,5oC Interpretation :
Normal
GENERAL STATUS
Head : Mesocephal, alopesia (-)
Static RR : 24x/min, Hyper pigment (-), spider nevi RR : 24x/min, Hyper pigment
(-), atrophy Pectoral Muscle (-), Hemithoraks D=S, ICS (-),spider nevi (-), Hemithoraks D=S,
Normal, Diameter AP < LL ICS Normal, Diameter AP < LL
Dynamic Up and down of hemitoraks D=S, abdominothorakal Up and down of hemitoraks D=S,
breathing, (-), muscle retraction of breathing (-), abdominothorakal breathing (-), muscle
retraction ICS (-) retraction of breathing(-),
retraction ICS (-)
Palpation Palpable pain(-), tumor (-), Arcus costae angle < 900, Palpable pain (-), tumor (-), Arcus costae angle <
enlargement of ICS (-), Stem fremitus D = S 900, enlargement of ICS (-), Stem fremitus D = S
Auskultation Vesicular (+), Whezzing (-), Ronchi (-) Vesicular (+), Whezzing (-),
Ronchi (-)
Intepretation :
Normal
CARDIAC EXAMINATION
Auscultation
Aortal valve : S1 & S2 standard, additional sound (-)
Intepretation : Cardiomegali
ABDOMEN EXAMINATION
Inspection : symetric, sycatric(-), striae(-),enlargement of vena (-),
caputmedusa (-).
Auscultation : peristaltic (+)
Palpation :
Superfisial : tight (-), mass (-), epigastrial pain (+)
Deep : abdominal pain (+), liver and kidney werent palpable, Murphys sign (+)
Percussion : tympani, side of deaf (-), shifting dullness (-)
Liver : right liver span 11 cm, left liver span 6 cm
Spleen : Throbe space percussion (-)
Intepretation : cholestasis
EXTREMITY EXAMINATION
Ekstremitas Superior Inferior
Intepretation : Normal
LAB. EXAMINATION
Examination Result
(31/08/2017)
Hb 10,3 g/dl
Ht 28,7 % Intepretation :
Leukosit 6,00 ribu/uL Anemia
Trombositopenia
Trombosit 462 ribu/uL Bilirubin total, direk,
Ureum 25 mg/dl indirek
SGPT
Creatinin 0,66 mg/dl
SGOT
Bilirubin Total 19,92 mg/dl
Bilirubin Direk 15,11 mg/dl
Bilirubin Indirek 4,81 mg/dl
SGOT 84 U/I
SGPT 69 U/I
HbsAg kualitatif Non reaktif
LAB. EXAMINATION
Examination Result Examination Result
(04/09/2017) (04/09/2017)
Hb 8,4 g/dl Natrium 131,8 mmol/L
Ht 23,2 % Kalium 4,70 mmol/L
Leukosit 4,70 ribu/uL Chloride 93,5 mmol/L
Trombosit 373 ribu/uL Calcium 7,9 mmol/L
APTT/PPTK 26,6 detik
PPT 10,4 detik Intepretation :
GDS 80 mg/dl Anemia
Ureum 15 mg/dl
Proteinemia
Albuminuria
Creatinin 0,76 mg/dl Hyponatremi
Total protein 5,2 g/dl
Hypochloremi
Hypocalsemi
Albumin 2,77 g/dl
Globulin 2,48 g/dl
LAB. EXAMINATION
Examination Result
Examination Result
(06/09/2017)
(07/09/2017)
Hb 11,0 g/dl
Calcium 8,5 mmol/L
Ht 31 %
Leukosit 5,22 ribu/uL Intepretation :
Hipokalsemi
Trombosit 287 ribu/uL
Natrium 129,5 mmol/L
Kalium 4,43 mmol/L
Chloride 91,0 mmol/L
Calcium 8,1 mmol/L
Intepretation :
Anemia
Hiponatremi
Hipokloremi
Hipokalsemi
ECG
31/08/17
ECG 31/08/2017
IRAMA : Sinus rhytm
REGULARITAS : Regular
FREKUENSI : 83x/menit
AXIS : L1 (+) AVF (+) Normo Axis Deviation
ZONA TRANSISI :-
GELOMBANG P : 0,04 s
PR INTERVAL : 0,12 s
QRS COMPLEX : 0,12 s
ST SEGMEN : ST depresi di V1-V6
GELOMBANG T : T inverted di V1-V6
Intepretation :
RBBB incomplete
X-RAY THORAX
COR : Apeks bergeser ke laterokaudal.
Elongasi dan kalsifikasi arcus aorta.
PULMO:
Corakan vaskular tidak meningkat.
Tak tampak gambaran infiltrat.
Diafragma dan sudut kostofrenikus tak tampak
kelainan.
KESAN :
CARDIOMEGALI ( SUSPEK LV)
ELONGASI DAN KALSIFIKASI ARCUS AORTA
PULMO TAK TAMPAK KELAINAN
CT-SCAN ABDOMEN
CT-SCAN ABDOMEN
X-RAY THORAX
- Tampak pelebaran ductus bilier intra hepatal dan ekstra hepatal
HEPAR : Ukuran normal, tepi rata, densitas homogen, nodul (-)
vena porta, vena hepatica tak melebar, vena cava inferior tak melebar
LIEN : Ukuran normal, densitas homogen, nodul (-), vena lien tak melebar
KE : Dinding tak melebar, batu (-), sludge (-)
PANKREAS : Ukuran normal, massa kistik di capt pankreas uk 2.19 x 2.33 cm
GINJAL KANAN : Ukuran normal, pielocayses system tak melebarm batu (-), kista (-)
GINJAL KIRI : Ukuran normal, pielocayses system tak melebarm batu (-), kista (-)
VESICA URINARIA : Dinding tak menebal, batu (-), massa (-)
Tak tampak pembesaran limfonodi
KESAN : CHOLESTASIS INTRA HEPATAL DAN EKSTRA HEPATAL E.C KISTA CAPUT PANKREAS UK
2.19 X 2.33 cm
Abnormal Data
Radiology Examination
Ro Thoraks :
Physical Examination Lab Chemistry
9. Cardiomegali 12. Anemia
History Taking 5. Cardiomegali
ECG 13. Trombositopenia
1.Abdominal pain 6. Murphys sign (+) 14. Hyperbilirubinemia
10. RBBB incomplete 15. SGOT, SGPT
2.Itchy skin 7. Icteric sclera
CT-SCAN ABDOMEN : 16. Hypoalbuminemia
3.Nausea 8. eritematous skin (+),thick 17. Hyponatremi
11. Cholesistasis intra hepatal 18. Hypochloremi
4.Vomiting skuama (+)
dan ekstra hepatal e.C kista 19. Hypocalsemi
4 5 6
HYPOCALSEMIA HYPOALBUMINEMIA RBBB INCOMPLETE
(19) (16) (10)
1. HYPERBILIRUBINEMIA
Ass :
Pharmacology :
Ursodeoxicolicacid 2 x 1 cholestasis
Non Pharmacology :
Ass :
Hipokrom mikrositer anemia defisiensi Fe, anemia akibat penyakit kronis, thalassemia
Normokrom normositer anemia pasca perdarahan akut, anemia hemolitik, anemia akibat
penyakit kronis, anemia pada keganasan hematologi
Makrositer anemia defisiensi asam folat / B12
Ip. Dx :
Clinical sign of anemia, bleeding history, DR
Laboratorium darah
indeks eritrosit (MCV, MCH, MCHC)
hapusan darah tepi
Konsentrasi Besi Serum dan TIBC
Feritin Serum
Pemeriksaan sumsum tulang
Coomb test
Ip. Tx :
Pharmacology :
Sulfas Ferrosus 3 x 200 mg
Vitamin C 3 x 1
Ip. Mx :
Keadaan umum
Ip. Ex :
1. Menjelaskan pengertian dan sebab anemia
2. Menjelaskan untuk makan secara teratur
3. Memperbanyak menu yang dianjurkan
4. Menjelaskan untuk meminum obat yang diberikan secara teratur
3. HYPONATREMI
Ass :
Increase of amount fluid intake
Inability to suppress the ADH secretion sirosis hepatis, CHF
Ip. Dx : -
Ip. Tx :
Natrium correction 0,6 x 65 x (140 - 131,8) = 319,8 mEq/L
NaCl 0,9 % 2 flabot 1 flabot NaCl 0,9 % : Na 154 meq/L ; Cl 154 meq/L
Ip. Ex : -
5. HYPOALBUMIN
Ass :
Etiology Penyakit hati (akut, kronis)
Ip. Dx : -
Ip. Tx :
koreksi albumin 0,8 x 65 x (3,5-2,77) = 17,16 gram
Albumin intake 20 % in 100 cc = 20 gr
Ip. Mx : Kadar albumin
Ip. Ex :
High albumin intake
6. RBBB
Ass :
Normal variant
Congenital heart disease ASD, VSD
Ip. Dx : ECG
Ip. Tx : -
Ip. Mx : ECG
Ip. Ex : -
4. HYPOCALSEMIA
Ass :
Vitamin D deficiency low fat intake
disturbed of vitamin D metabolism
Ip. Dx : -
Ip. Tx :
Calcium serum = 7,9 mg/dL 1,97 mmol/L