Case report

Subjective Data
Name : Ms. Tiur Minarma Sirait
Date of Administration : March, 11st 2015
Chief Complain : Epigastric pain
 Anamnesis
Main symptom : Epigastric pain
Additional 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 History
there was no family member that have the same symptoms
Hypertension and cancer runs in the family

Social History
Patient liked to eat instant noodle when she was a child
Patient didnt get exclusive breast feeding. She got breast feeding until she was 1 month
Patients mother is a active smoker and only stop when she was pregnant.
 11 March 2015

Findings Assesment Therapy Planning

Stomachache like it was puncture Scale 2 -3 Abdominal Buscopan 2 x 1 amp IVFD : II RL / 24 jam
GCS: E4V5M6, TD: 100/60, PR 70x, T : 37oC, RR: 18x pain Rantidine 2 x 1 amp Mm :
Eye : Pale Conjungtiva -/-, Sclera icteric -/- Musin 3 x 1 sm Buscopan 2 x 1 amp
THT : Normal Rantidine 2 x 1 amp
Neck : Lymph Nodes not Enlarged Musin 3 x 1 5m
JVP : not distended
THRORAX
Insp: Intercostal retraction
Pal: Vocal fremitus sound symmetris dextra = Sinistra
Per : Symmetric sonor sound
Aus : Basic sound of breath vesical, wheezing -/-, ronchi -/-
ABDOMEN
Ins : flat
Aus : Bowel sound (+) 4x/minute
Pal : Pressure pain (-)
Per : tympani
Extremitas : pitting oedem (-), cold acral, CRT < 2, turgor
normal
 12 March 2015

Findings Assesment Therapy Planning

Pain on upper abdomen Abdominal Buscopan 2 x 1 amp IVFD :
GCS: E4V5M6, TD: 110/70, PR 80x, T : 36,5oC, RR: 19x pain Rantidine 2 x 1 amp II RL
Eye : Pale Conjungtiva -/-, Sclera icteric -/- Musin 3 x 1 5m I Clinimix + Clinoleic 100cc
THT : Normal Omeprazole 2 x 1 fial
Neck : Lymph Nodes not Enlarged Vitazym 3 x 1 opt Puasa
JVP : not distended
THRORAX Mm :
Insp: Intercostal retraction Buscopan 2 x 1 amp
Pal: Vocal fremitus sound symmetris dextra = Sinistra Rantidine 2 x 1 amp
Per : Symmetric sonor sound Musin 3 x 1 5m
Aus : Basic sound of breath vesical, wheezing -/-, ronchi -/- Omeprazole 2 x 1 fial
ABDOMEN Vitazym 3 x 1 opt
Ins : flat
Aus : Bowel sound (+) 4x/minute
Pal : Pressure pain (-)
Per : tympani
Extremitas : pitting oedem (-), cold acral, CRT < 2, turgor
normal
 13 March 2015

Findings Assesment Therapy Planning

Pain on upper abdomen Acute Cefoperazone 2 x 1 amp IVFD :
GCS: E4V5M6, TD: 110/70, PR 70x, T : 36,5oC, RR: 20x Pancreatitis Pantozol 2 x 1 flc II RL
Eye : Pale Conjungtiva -/-, Sclera icteric -/- I Clinimix + I Clinoleic
THT : Normal
Neck : Lymph Nodes not Enlarged Puasa
JVP : not distended
THRORAX Mm :
Insp: Intercostal retraction Cefoperazone 2 x 1 gr
Pal: Vocal fremitus sound symmetris dextra = Sinistra Pantozol 2 x 1 flc
Per : Symmetric sonor sound
Aus : Basic sound of breath vesical, wheezing -/-, ronchi -/- Check Triglieserida
ABDOMEN Check CEA, Ca 19-9
Ins : flat
Aus : Bowel sound (+) 4x/minute
Pal : Pressure pain (-)
Per : tympani
Extremitas : pitting oedem (-), cold acral, CRT < 2, turgor
normal
 14 March 2015

Findings Assesment Therapy Planning

Epigastric pain became less painful Pancreatitis IVFD/
Nausea II RL
GCS: E4V5M6, TD: 100/70, PR 72x, T : 36.7oC, RR: 18x
Eye : Pale Conjungtiva -/-, Sclera icteric -/- Diet:
THT : Normal Puasa
Neck : Lymph Nodes not Enlarged
JVP : not distended MM/
THRORAX Cefoperazone 2 x 1 gram
Insp: Symmetris Pantazol 2 x 1 Fic
Pal: Vocal fremitus sound symmetris dextra = Sinistra Omeprazole 2 x 1 ops
Per : Symmetric sonor sound
Aus : Basic sound of breath vesical, wheezing -/-, ronchi -/-
ABDOMEN
Ins : flat
Aus : Bowel sound (+) 7x/minute
Pal : Pressure pain (-)
Per : tympani
Extremitas : pitting oedem (-), warm acral, CRT < 2, turgor
normal
 15 March 2015

Findings Assesment Therapy Planning

Epigastric pain Pancreatitis IVFD/
Nausea II RL
GCS: E4V5M6, TD: 110/70, PR 79x, T : 36.4oC, RR: 20x
Eye : Pale Conjungtiva -/-, Sclera icteric -/- Diet:
THT : Normal Puasa
Neck : Lymph Nodes not Enlarged
JVP : not distended MM/
THRORAX Cefoperazone 2 x 1 gram
Insp: Symmetris Pantazol 2 x 1 Fic
Pal: Vocal fremitus sound symmetris dextra = Sinistra Omeprazole 2 x 1 ops
Per : Symmetric sonor sound
Aus : Basic sound of breath vesical, wheezing -/-, ronchi -/-
ABDOMEN
Ins : flat
Aus : Bowel sound (+) 6x/minute
Pal : Pressure pain (-)
Per : tympani
Extremitas : pitting oedem (-), warm acral, CRT < 2, turgor
normal
 16 March 2015

Findings Assesment Therapy Planning

Epigastric pain became less painful Pancreatitis IVFD : -
Nausea
GCS: E4V5M6, TD: 100/70, PR 98x, T : 36.5oC, RR: 18x
Eye : Pale Conjungtiva -/-, Sclera icteric -/- Diet:
THT : Normal Puasa
Neck : Lymph Nodes not Enlarged
JVP : not distended MM/
THRORAX Musin 3 x 1 sm
Insp: Symmetris Omeprazole 2 x 1 cps
Pal: Vocal fremitus sound symmetris dextra = Sinistra
Per : Symmetric sonor sound
Aus : Basic sound of breath vesical, wheezing -/-, ronchi -/-
ABDOMEN
Ins : flat
Aus : Bowel sound (+) 7x/minute
Pal : Pressure pain (-)
Per : tympani
Extremitas : pitting oedem (-), warm acral, CRT < 2, turgor
normal
 17 March 2015

Findings Assesment Therapy Planning

- Pancreatitis IVFD/ -

GCS: E4V5M6, TD: 100/70, PR 96x, T : 36.8oC, RR: 18x Diet:

Eye : Pale Conjungtiva -/-, Sclera icteric -/- Lunak
THT : Normal
Neck : Lymph Nodes not Enlarged MM/
JVP : not distended Musin 3 x 1 SM
THRORAX Omeprazole 2 x 1 cps
Insp: Symmetris
Pal: Vocal fremitus sound symmetris dextra = Sinistra
Per : Symmetric sonor sound
Aus : Basic sound of breath vesical, wheezing -/-, ronchi -/-
ABDOMEN
Ins : flat
Aus : Bowel sound (+) 7x/minute
Pal : Pressure pain (-)
Per : tympani
Extremitas : pitting oedem (-), warm acral, CRT < 2, turgor
normal
 18 March 2015

Findings Assesment Therapy Planning

- Pancreatitis IVFD/ -

GCS: E4V5M6, TD: 100/70, PR 94x, T : 36.7oC, RR: 20x Diet:

Eye : Pale Conjungtiva -/-, Sclera icteric -/- Lunak
THT : Normal
Neck : Lymph Nodes not Enlarged MM/
JVP : not distended Musin 3 x 1 SM
THRORAX Omeprazole 2 x 1 cps
Insp: Symmetris
Pal: Vocal fremitus sound symmetris dextra = Sinistra
Per : Symmetric sonor sound
Aus : Basic sound of breath vesical, wheezing -/-, ronchi -/-
ABDOMEN
Ins : flat
Aus : Bowel sound (+) 8x/minute
Pal : Pressure pain (-)
Per : tympani
Extremitas : pitting oedem (-), warm acral, CRT < 2, turgor
normal
 Clinical Laboratory

11/03/2015
LED : 23 mm/hours (H) (N : 0 20 mm) Kreatinin : 0.6 mg/dL (N : 0,6 -11)
Hb : 11.7 g/dL Na Blood : 141 mEq/L (N :135 147 mEq/L)
Leucosite : 15.400/uL (H) (N : 5 10 ribu) K Blood : 4.5 mEq/L (N : 3,5 5 mEq/L)
Hematocrite : 35 % Albumin : 3.2 g/dL (L) (N : 3,4 4,8 g/dL)
SGOT : 20 u/L (N : < 35 U/I) Globulin : 4.1 g/dL (H) (N : 1,3 3,7 g/dL)
SGPT : 19 u/L (N : < 35 U/I) Amilase : 208 U/L (H) (N : < 115 U/L)
Ureum : 15 mg/dL (N : 10 50 mg/dl) Lipase : 3447 U/L (H) (N : 73 393 U/L)
 Clinical Laboratory

12/03/2015

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 Laboratory

13/03/2015

Trigliserida : 83 mg/dL (N : < 200 mg/dL)

CEA : 1.44 ng/mL (N : <= 5 ng/mL)
CA 19-9 : 226.11 U/mL (H) (N : <= 37 U/mL)
MRCP Abdomen
MRCP Abdomen
Thank You