DUTY REPORT

August 13TH 2014

Doctor on duty
:
dr. Arlis,
dr. Karen
Co-assistant
:
Karina, Citra

PATIENT RECAPITULATION
Inpatient
Outpatient
Ward

5
:
:

4
1

IDENTITY
1.
2.
3.
4.
5.
6.
7.
8.
9.

Name :
Ms. N
Sex
:
Female
MR no :
44.05.32
Age
:
26 years old
Job
:
Employee
Religion:
Moslem
Marital Status
:
Single
Ethnic/Race :
Javanese
Address:
Bulakan RT 01/03 tempuran
paron

ANAMNESIS
Autoanamnesis on 13/8/14 at 23.39 PM in
the RSPAD Gatot Soebroto Emergency
Room.
Chief Complaint:
upper abdominal pain 3 days before
admission to ER
Additional Complaint:
nausea, loss of appetite

CURRENT ILLNESS
Since 3 days ago patient has felt pain in her
upper abdominal. It is an intermittent pain that
hasnt worsened by her daily activity. Her
abdominal pain felt like being squeezed. It is full,
but the pain didnt spread. Chest pain symptom
like heart burn was not felt by the patient.
Patient felt bloating in her stomach. She had
nausea but she didnt vomit. Her symptoms
made her lose appetite.
Since 2 days ago her symptoms has worsened.
Her full and pain symptoms got worse. Her
nausea got worse too. She only ate 2 spoons of
food for three times a days, and was satiated
quickly. She had no fever, cough and rhinitis.

Patient hasnt taken any medication. This

symptom is a recurrent symptom. She
consumed one cup of coffee every
morning, but for the last 2 weeks she
drank 2 cups of coffee because she had
to work overtime. She usually ate fried
and spicy foods. Because she was busy,
she didnt eat three times a day. She only
ate once with a big portion. Patient is a
none smoker and none alcoholic. Patient
doesnt have any allergy.

PAST ILLNESS
Hypertension (-)
DM (-)

FAMILY ILLNESS
There are no member of the family
that has same symptoms with the
patient

PHYSICAL EXAMINATION
VITAL SIGNS
General State
Consciousness
Blood Pressure
Pulse
Respiratory Rate
Temperature
Body Weight
Body Height
BMI

:
:
:
:
:

:
:

Moderate Sickness
Compos Mentis
110/70 mmHg
80 x/minute
24 x/minute
:
36.2oC
:
53 kg
158 cm
21,2 (Normoweight)

PHYSICAL EXAMINATION
General Examination
Head

: Normocephal

Eye

: anemic conjunctiva (-/-, icteric sclera (-/-)

Ears

: normotia, discharge (-)

Nose

: septum deviation (-), discharge (-)

Mouth

: dry mucous, oral trush (-), leukoplakia (-)

Neck

: lymph nodes enlargement (-) JVP 5-2 cmH2O

Thorax

: symmetric, intercostal retraction (-)

Cor

: regular 1st and 2nd heart sound, murmur (-), gallop (-)

Pulmo

: vesicular breathing sounds, rales / crackles (-/-)

ronchi (-/-) wheezing (-/-)

Abdomen

: distended (-), bowel sound within normal limit,

tympani, hepar & lien not palpable, epigastric tenderness

Extremities

: warm, pitting edema (-), clubbing (-), cyanosis (-)

CRT < 2 seconds

DIAGNOSTIC PLANS
LABORATORIUM
JENIS PEMERIKSAAN

HASIL

NILAI RUJUKAN

Hb

13,9

13 - 18 g/dl

Ht

42

40 52 %

Erythrocyte

4,9

4.3 - 6.0 mil /ul

Leukocyte

6.700

4800 - 10800/ul

Thrombocyte

169.000

150000 - 400000/ul

MCV

93

80 96 fL

MCH

28

27 - 32 pg

MCHC

33

32 36 g/dL

Routine Hematology

RESUME
Patient was admitted to ER with upper abdominal pain
since 3 days ago. It is an intermitten pain, the pain felt like it
being squeeze, but the pain doesnt spread. Her abdominal
felt full and bloating. Pain also accompanied by nausea, and
anorexia. This is a repeat symptoms for her.
On Personal Examination, hemodinamik stabil, and
patient has epigastric tenderness.

PROBLEMS LIST
1. Dyspepsia Syndrome

assesment
Dyspepsia Syndrome
Anamnesis : Upper abdominal pain,
bloating, nausea
Physical Exam : Epigastric
tenderness

Therapy
Non Therapeutic Plan
Diet plan
1. Soft diet 1600 kcal
2. Eat 5 times a day (3 times with full
meals and 2 times in between with
snacks)
3. Avoid foods that could cost high
acidity
in gaster such as coffee, spicy
food and
unsaturated fats

Therapeutic Plan
IVFD Nacl 0.9%
Ondansentron 2 x 4 mg iv
Omeprazole 1 x 40 mg iv