Duty Report (IGD)

2 August 2017

Supervisor : Dr .dr. Soroy Lardo, Sp.PD FINASIM

Identitas Pasien

Name : Nn. VO
Age : 19 y.o
Gender : female
Address : Central Jakarta
Job : student
Religion : Islam
Nationality : Indonesia
Status : Single
 Anamnesis (Autoanamnesis)

Chief complain Nausea and vomiting since 3 days

before entering the hospital

The patient came with nausea and vomiting since 3 days ago.
Nausea appears when patient was eating and better when she
drinks. Vomiting 3 times a day. It contains fluid, no blood or black
vomiting. She also feels pain on upper stomach, it continues and the
quantity of pain is 4 of 10. she has gastritis history, she was ever been
in this condition before and she took antasid and get better. Fever is
denied. Defecation and micturition is normal.
 Gastrisis was proved Food/drug alergy (-)
Past illness history HT was denied
DM was denied
Asthma was denied

HT was denied
Family illness history DM was denied
Asthma was denied

Treatment history antasid

Irregular eating habit

Like spicy food
Social History Smoking habit (-)
Alcohol consumption
habit (-)
 Physical Examination
GENERAL STATUS
General state : mild illness
Consiousness : Compos Mentis, GCS: 15 (E4V5M6)
Vital Sign :

BP: 130/90 Pulse: 90 RR: 20 Temp:

mmHg bpm x/min 36.6C

Nutrition BH : 156 cm
BW : 50 Kg BMI: 20,54 normoweight
status
Head to Toe
Head : Normocephal, normal hair distribution
Eye : Pale Conjungtiva -/-, Sclera icteric -/-
Ear, Nose, Throat : no abnormalities
Mouth : moist lips & mucosa, cyanosis (-)
Neck : lymph node enlargement (-)
Thorax (Pulmo)

Inspection : normal chest shape, Symmetric while

breathing, no retraction of intercostae space
Palpation : symmetric tactile fremitus, symmetric chest
expansion
Percussion : Resonant sound bilateraly (sonor)
Auscultation : Vesicular breathing sound bilaterally
(+), Rhonki (-), Wheezing (-)
Thorax (Cor)

Inspection : No visible ictus cordis

Palpation : Ictus cordis at ICS 5 linea midclavicula sinistra
Percussion :
Left margin : ICS V linea left midsternalis
Right margin : ICS V linea left mid clavicle
Upper margin : ICS IV linea left parasternal
Auscultation : Normal S1-S2 are heard, murmur (-),
Gallop (-)
Abdomen

Inspection : normal countour, caput medusa (-)

Auscultation : normal bowel movement
Palpation : soft, pain when palpating epigastric
region, normal turgor, no palpable liver and
spleen,
Percussion : tympanic in all area, Shifting dullness
(-)
Ekstremitas

Warm acral
Sianosis (-)
Edema (-)
CRT < 2 sec
 Labotatory
Findings
Hb : 12,0
darah rutin Ht : 40%
Leukosit : 7580
Trombosit : 175.500
MCV : 90
MCH : 27
MCHC : 33
Resume

Nn. VO with nausea and vomiting since 3 days ago. Nausea appears when
patient was eating and better when she drinks. Vomiting 3 times a day. It
contains fluid, no blood or black vomiting. She also feels pain on upper
stomach, it continues and the quantity of pain is 4 of 10. she has gastritis
history
Phusical exam : localis status: pain when palpating epigastric region
Laboratory findings is normal
Problem List

1. Syndroma Dyspepsia
PROBLEM SOLVING
1. Sindroma dispepsia
An: nausea and vomiting, feels pain on upper stomach, gastritis history (+)
Phusical exam : localis status: pain when palpating epigastric region
Diagnostic plan: electrolite, endoscopy
Dd: gastritis, GERD, ulkus peptikum
therapy plan:
Ondansentron 3 x 4 mg
Omeprazol 1 x 40 mg
Ranitidin 2 x 150 mg
Education:
avoid eating high fatty, spicy and sour food
The pattern od eating is small but reguler
prognosis

Ad vitam : dubia ad bonam

Ad functionam : dubia ad bonam
Ad sanationam : dubia ad bonam
Definisi
Etiologi
Klasifikasi
Klasifikasi
Pemeriksaan Penunjang Diagnosis
Terapi

Antasida
Penyekat H2 Reseptor
Penghambat pompa proton
Sitoproteksi
Obat golongan prokinetik
Metokloperamid
Domperidon
Cisapride
Agonist motilin