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Patient’s Identity
• Name : Mr. Ky• Age : 19 y.o• Religion : Moeslim• Date admission : July 27 2014• Adrress : Balongrejo - Lamongan
Anamnesis
• Chief complaint: abdominal discomfort• Present illnes: Patient was admission on Emergency
department of Muhammadiyah Lamongan hospital because he feel abdominal discomfort since 2 month before hospitalized. Abdominal discomfort especially after eating, he is often burp. Nausea +. Vomiting -. Pain the stomach -, epigastric pain – . Urination and defecation are normal. Patien have been treated but not change.
Anamnesis
• History or past illness : - Alergy -, DM -, Hypertensi -, gastritis -
• History of family : Denial
• History of past treatment :– Omeprazole– Trimetoprim+sulfametoksazole– Fucohelix
Physic Examinations
• GCS : 456, Compos Mentis• Vital Sign
BP : 122/98 mmHgPulse : 98x / minutesRR : 20x / minutesTemp : 36°C
Physic Examinations
• Head and neck : – Anemic-/ icteric-/ cyanosis-/ dyspneu-
• Thorax : – Pulmo :
• I : Simetric, retraction -/-• P : fremitus + simetric• P : sonor/ sonor• A : ves/ves, rh -/-, wh (-/-)
• Cor : • I : vassoure cardiaque -• P : ictus cordis not palpable• P : heart limit are normal• A : S1-S2 single, murmur(-), gallop(-)
Physic Examinations
• Abdomen : – I : flat– P : soepel, hepar and lien not palpable, pain -– P : tympani – A : bowel sound (+N) ,
• Extremity : warm, dry, red, edema –
Planning
• Planning Dx :– CBC– SE
• Planning Tx :– Asering 1500 cc/24 hour– Rantin 2x50 mg IV
• Planning Monitoring• Complaint• Vital sign
Prognosis
• Dubia ad bonamEducation
• Explain to the family about the condition of this patient now, its disease, about its examinations, theraphy and intervention will be done, and also about complication and prognosis.