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Wednesday , May 3rd 2017

DM in charge
Amuthen Karunagaran

Supervisor :
Dr Fajar SpPD
Mrs. T/53 y.o / W.28
Chief Complain: Stomach ache

History Taking : Autoanamnesa:

Patient came to the ER with chief complain of stomach ache since
7 months ago. She feels discomfort intermittently. She feels warm
sensation at her stomach in the epigastric region. She has been
admitted for the same problem 3 months ago in Anisa Hospital
Patient also complained of nausea and vomiting about 6 times a
day and it consist of eaten food or even sometimes is watery and
white in colour the volume was about a small glass, blood(-).
Patient was unable to defecate for the past 7 days, before
admission patient admitted having black stool one time. Patient
was having difficulty to defecate for the past one month.
Past Medical History & Medication :
She was admitted in Anisa 3 months ago for the same complain. She
was admitted regularly in Ngudi Waluyo hospital for stomachache as
the probleem always relapses.

Family History :
No history of diabetes and hypertension in her family.

Lifestyle and Social History :

Patient works as a farmer and has 2 kids. Patients husband is a

Allergy :
No known history of food or drug allergy.
General appearance looked moderately ill Looked normoweight
GCS 456
BP 110/70 mmHg PR = 80 bpm RR = 18 tpm Tax =36,4 0C
Head Conjuctiva Anemic (+) Sclera Icteric (-)

Neck JVP R + 0 cm H20, 300 position

Chest Heart Ictus invisible & palpable at ICS V MCL sinistra
S1, S2 single, murmur - gallop -
RHM ~SL D, LHM ~ ictus
Lung Symmetric Stem fremitus v v Rh - - Wh - -
v v - - -
v v - - -
Abdomen Rounded(+), bowel sound normal, epigastrial tenderness (+), liver
span 8 cm, Traubes space tympani
Extremities leg edema (+/+)
Warm acral,
Laboratory finding
Lab Value (Normal) Lab Value (Normal)
Hemoglobin 6.7 11,4 - 15,1 Natriu 111.8 136-145 mmol/L
g/dl m
Eritrosit 2.51 4.0-5.0 / L Kaliu 2.03 3,5-5,0 mmol/L
leukocyte 6.5 4.700 Chlori 78.1 98-106 mmol/L
11.300 /L da
HCT 20.2 38 - 42%

Trombocyte 291000 142.000

424.000 /L
MCV 80.80 80-93 f

MCH 26,60 27-31 pg

MCHC 33,10 32-36g/dL

SGOT 13 0-32 mU/dL

SGPT 13 0-33 mU/dL

Ureum 33 16,6 -
Creatinine 1.16 < 1,2 mg/dl
CUE AND CLUE Problem Initial Planning Planning Therapy Pmo &
List Diagnosis Diagnosis Pedu
Female/52 y.o. 1. 1.1 PUD Endoscopy Inj. Omeprazole S, VS
History Dyspepsia 1.2 Gastritis 1x40mg
Patient came to the ER Syndrome Erosiva Inj. Metoclopramide P.Edu:
with chief complain of 3x10mg explanatio
nausea and vomiting about n about
6 times a day, volume is the
about one small cup and disease
contains food. and
Patient also complained of treatment
stomach ache since 7 plan
months ago.

Physical examination
Epigastrial tenderness(+)
CUE AND CLUE Problem Initial Planning Planning Therapy Pmo &
List Diagnosis Diagnosis Pedu
Mr.S/ 47 yo/ W27 2. Anemia 2.1 Acute Blood - PRC transfusion 2 Complaint
Ax normokro blood smear packs/day till Vital sign
Conjunctiva anemic(+) m loss Reticulo Hb>10g/dL Subjective
normositer 2.2 Chronic cyte
PE disease count HB level
BP: 110/70 mmHg
HR: 80x/m Anemic
RR: 18x/m sign
Tax: 36.4 C
Lab : and
HB 6.70 g/dL prognosis
MCV : 80.80
MCH : 26.60
MCHC : 33.10
CUE AND CLUE Problem Initial Planning Planning Therapy Pmo &
List Diagnosis Diagnosis Pedu
Female/73 YO 3. 3.1 iritable Colonoscopy -Lectulose syrup 3xcth Education:
History Constipati bowel Explain
Patient unable to defecate on syndrome about
for the past 7 days. 3.2 condition,
Weight loss(+) Malignancy planning
PE and
Adbomen rounded(+) prognosis
GCS : 456
BP : 120/70 mmHg
HR : 85 x/m
RR : 18 x/m
Tax : 36,8 C