Case report

Subjective DataName: Ms. Tiur Minarma SiraitDate of Administration: March, 11st 2015Chief Complain: Epigastric pain

AnamnesisMain symptom : Epigastric painAdditional symptom : nausea

Patient came to PGI Cikini hospital with pain at epigastric area since morning. The patient felt this all day. The pain that she felt it feels like it was punctured. The pain didnt reduce when she move around. The pain occurred when she eat something greasy and gain weight. Before admitted , patient had kwetiau. Nausea (+), vomitting (-), decreased in appetite(+), stomach ache (-).

Past Medical History and Treatment

At 7 years old, patient had epigastric pain and jaundice all over the body, because of that patient go to hospital and get cholecystectomy et cause cyst on CBD. Because of that patient cant eat any kind of greasy food.At 2012, patient went to other hospital because she had epigastric pain, nausea and vomiting without jaundice. She had hepatico-jejunostomy. The doctor said that the surgery when she was 7 years old didnt go well.

At April 2014, she had same symptoms and was brought to the hospital but she didnt want to get admitted.

Family Historythere was no family member that have the same symptoms Hypertension and cancer runs in the family

Social HistoryPatient liked to eat instant noodle when she was a childPatient didnt get exclusive breast feeding. She got breast feeding until she was 1 monthPatients mother is a active smoker and only stop when she was pregnant.

11 March 2015

FindingsAssesmentTherapyPlanningStomachache like it was puncture Scale 2 -3 GCS: E4V5M6, TD: 100/60, PR 70x, T : 37oC, RR: 18xEye : Pale Conjungtiva -/-, Sclera icteric -/-THT : NormalNeck : Lymph Nodes not EnlargedJVP : not distendedTHRORAXInsp: Intercostal retractionPal: Vocal fremitus sound symmetris dextra = SinistraPer : Symmetric sonor soundAus : Basic sound of breath vesical, wheezing -/-, ronchi -/-ABDOMENIns : flatAus : Bowel sound (+) 4x/minutePal : Pressure pain (-)Per : tympaniExtremitas : pitting oedem (-), cold acral, CRT < 2, turgor normalAbdominal pain Buscopan 2 x 1 ampRantidine 2 x 1 ampMusin 3 x 1 sm

IVFD : II RL / 24 jamMm : Buscopan 2 x 1 ampRantidine 2 x 1 ampMusin 3 x 1 5m

12 March 2015

FindingsAssesmentTherapyPlanningPain on upper abdomen GCS: E4V5M6, TD: 110/70, PR 80x, T : 36,5oC, RR: 19xEye : Pale Conjungtiva -/-, Sclera icteric -/-THT : NormalNeck : Lymph Nodes not EnlargedJVP : not distendedTHRORAXInsp: Intercostal retractionPal: Vocal fremitus sound symmetris dextra = SinistraPer : Symmetric sonor soundAus : Basic sound of breath vesical, wheezing -/-, ronchi -/-ABDOMENIns : flatAus : Bowel sound (+) 4x/minutePal : Pressure pain (-)Per : tympaniExtremitas : pitting oedem (-), cold acral, CRT < 2, turgor normalAbdominal pain Buscopan 2 x 1 ampRantidine 2 x 1 ampMusin 3 x 1 5mOmeprazole 2 x 1 fialVitazym 3 x 1 opt

IVFD : II RL I Clinimix + Clinoleic 100cc Puasa

Mm : Buscopan 2 x 1 ampRantidine 2 x 1 ampMusin 3 x 1 5mOmeprazole 2 x 1 fialVitazym 3 x 1 opt

13 March 2015

FindingsAssesmentTherapyPlanningPain on upper abdomen GCS: E4V5M6, TD: 110/70, PR 70x, T : 36,5oC, RR: 20xEye : Pale Conjungtiva -/-, Sclera icteric -/-THT : NormalNeck : Lymph Nodes not EnlargedJVP : not distendedTHRORAXInsp: Intercostal retractionPal: Vocal fremitus sound symmetris dextra = SinistraPer : Symmetric sonor soundAus : Basic sound of breath vesical, wheezing -/-, ronchi -/-ABDOMENIns : flatAus : Bowel sound (+) 4x/minutePal : Pressure pain (-)Per : tympaniExtremitas : pitting oedem (-), cold acral, CRT < 2, turgor normalAcute Pancreatitis Cefoperazone 2 x 1 ampPantozol 2 x 1 flc

IVFD : II RL I Clinimix + I Clinoleic Puasa

Mm : Cefoperazone 2 x 1 grPantozol 2 x 1 flc

Check TriglieseridaCheck CEA, Ca 19-9

14 March 2015

FindingsAssesmentTherapyPlanningEpigastric pain became less painfulNausea GCS: E4V5M6, TD: 100/70, PR 72x, T : 36.7oC, RR: 18xEye : Pale Conjungtiva -/-, Sclera icteric -/-THT : NormalNeck : Lymph Nodes not EnlargedJVP : not distendedTHRORAXInsp: SymmetrisPal: Vocal fremitus sound symmetris dextra = SinistraPer : Symmetric sonor soundAus : Basic sound of breath vesical, wheezing -/-, ronchi -/-ABDOMENIns : flatAus : Bowel sound (+) 7x/minutePal : Pressure pain (-)Per : tympani Extremitas : pitting oedem (-), warm acral, CRT < 2, turgor normalPancreatitis IVFD/ II RL

Diet:Puasa

MM/Cefoperazone 2 x 1 gramPantazol 2 x 1 FicOmeprazole 2 x 1 ops

15 March 2015

FindingsAssesmentTherapyPlanningEpigastric painNausea GCS: E4V5M6, TD: 110/70, PR 79x, T : 36.4oC, RR: 20xEye : Pale Conjungtiva -/-, Sclera icteric -/-THT : NormalNeck : Lymph Nodes not EnlargedJVP : not distendedTHRORAXInsp: SymmetrisPal: Vocal fremitus sound symmetris dextra = SinistraPer : Symmetric sonor soundAus : Basic sound of breath vesical, wheezing -/-, ronchi -/-ABDOMENIns : flatAus : Bowel sound (+) 6x/minutePal : Pressure pain (-)Per : tympani Extremitas : pitting oedem (-), warm acral, CRT < 2, turgor normalPancreatitis IVFD/ II RL

Diet:Puasa

MM/Cefoperazone 2 x 1 gramPantazol 2 x 1 FicOmeprazole 2 x 1 ops

16 March 2015

FindingsAssesmentTherapyPlanningEpigastric pain became less painfulNausea GCS: E4V5M6, TD: 100/70, PR 98x, T : 36.5oC, RR: 18xEye : Pale Conjungtiva -/-, Sclera icteric -/-THT : NormalNeck : Lymph Nodes not EnlargedJVP : not distendedTHRORAXInsp: SymmetrisPal: Vocal fremitus sound symmetris dextra = SinistraPer : Symmetric sonor soundAus : Basic sound of breath vesical, wheezing -/-, ronchi -/-ABDOMENIns : flatAus : Bowel sound (+) 7x/minutePal : Pressure pain (-)Per : tympani Extremitas : pitting oedem (-), warm acral, CRT < 2, turgor normalPancreatitis IVFD : -

Diet:Puasa

MM/Musin 3 x 1 smOmeprazole 2 x 1 cps

17 March 2015

FindingsAssesmentTherapyPlanning -

GCS: E4V5M6, TD: 100/70, PR 96x, T : 36.8oC, RR: 18xEye : Pale Conjungtiva -/-, Sclera icteric -/-THT : NormalNeck : Lymph Nodes not EnlargedJVP : not distendedTHRORAXInsp: SymmetrisPal: Vocal fremitus sound symmetris dextra = SinistraPer : Symmetric sonor soundAus : Basic sound of breath vesical, wheezing -/-, ronchi -/-ABDOMENIns : flatAus : Bowel sound (+) 7x/minutePal : Pressure pain (-)Per : tympani Extremitas : pitting oedem (-), warm acral, CRT < 2, turgor normalPancreatitis IVFD/ -

Diet:Lunak

MM/ Musin 3 x 1 SMOmeprazole 2 x 1 cps

18 March 2015

FindingsAssesmentTherapyPlanning -

GCS: E4V5M6, TD: 100/70, PR 94x, T : 36.7oC, RR: 20xEye : Pale Conjungtiva -/-, Sclera icteric -/-THT : NormalNeck : Lymph Nodes not EnlargedJVP : not distendedTHRORAXInsp: SymmetrisPal: Vocal fremitus sound symmetris dextra = SinistraPer : Symmetric sonor soundAus : Basic sound of breath vesical, wheezing -/-, ronchi -/-ABDOMENIns : flatAus : Bowel sound (+) 8x/minutePal : Pressure pain (-)Per : tympani Extremitas : pitting oedem (-), warm acral, CRT < 2, turgor normalPancreatitis IVFD/ -

Diet:Lunak

MM/ Musin 3 x 1 SMOmeprazole 2 x 1 cps

Clinical Laboratory

Clinical Laboratory12/03/2015

Albumin : 3.2 g/dL (L) (N : 3,4 4,8 g/dL)Globulin: 4.1 g/dL (H) (N : 1,3 3,7 g/dL)Amilase: 208 U/L (H) (N : < 115 U/L)Lipase : 3447 U/L (H) (N : 73 393 U/L)

Clinical Laboratory13/03/2015

Trigliserida: 83 mg/dL (N : < 200 mg/dL)CEA : 1.44 ng/mL (N :

MRCP Abdomen

MRCP Abdomen

Thank You

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