Coass: Fathin and LaresiResident: dr. Martua

General practitioner: dr. AnanitaSupervisor : dr Soroy Lardo SpPD FINASIM

Department Of Internal MedicineIndonesia Army Central Hospital Gatot Seobroto

DUTY REPORTTHURSDAY, 12 JUNE 2014

PATIENT RECAPITULATIONIn patient

3rd floor : 2 patient

4th floor : 2 patient

5th floor : 2 patient

Ms. Gadis,20 y.o, with dyspepsia and suspect UTI

6th floor : 2 patient

Out patient : 0 patient

Death : 0 patient

I. PATIENT IDENTITY

Patient Initial : Ms. GDate of Birth : March 5, 1994Age : 20 yoSex : FemaleAddress : Dsn Mrogian RT 01/02 Dandang Gendis Pasuruan, East JavaMarital Status : SingleMedical Record number: 714374Date of admission : June 11, 2014.

II. BASIC DATA

1. ANAMNESIS (Autoanamnesis)

Chief complaint: Patient came with upper abdominal pain since 5 hours before admission.

HISTORY OF PRESENT ILLNESS :

• Patient complained of upper abdominal pain, headache, fever, fatigue, nausea and vomiting.

• The pain was persistent. Localized at upper and also lower abdomen. The pain is not related to eat, menstruation, defecation, and urination.

• She only vomit once in the morning, containing food.

• There was no diarrhea, constipation, and faeces changes (normal consistency, no blood, and no mucus).

• She feels to urinating more often and waking from sleep to urinate. There was no urine changes.

• She has fever since last night

5 hour before admission

• No history of gastric contain reflux, any acid taste in her mouth, or hoarseness.

• There is no referred pain from stomach to right quadrant of abdomen spreading to shoulder and back

Diet history:

• She has bad appetite, only eat twice a day, small portion and early satiated.

• 1 week before admission she noticed a vaginal discharge, yellow color, bad smell.

• She used to have stomach problem before. She already went to the doctor and consumed Antacid without any improvement.

• There is no history of surgery or hospitalization before

HISTORY OF PAST ILLNESS :

HABITS:

• She neither smoking nor drinking.

• She never consume any painkiller drugs (aspirin, nsaid; ibuprofen,naproxen)

• History of sexual intercourse (+)

TREATMENT HISTORY:

• Antacid (Mylanta, Promag)

• No one in her family who has any similar problem.

• No history of Diabetes Melitus, Hypertension,and allergic.

FAMILY HISTORY:

Physical Examination

•General state : Moderate illness

•Consciousness : Compos mentis

•Nutritional State : Well-nourished

Vital Sign

•Blood pressure : 127/71 mmHg

•Pulse : 80 x/mnt, regular.

•Respiratory rate : 22 x/mnt, thorakoabdominal, kussmaul breathing (-)

•Temperature : 37.9 ⁰C

•Body weight : 48 kg

•Body Height : 150 cm

•BMI : 21,8 (normoweight)

PHYSICAL EXAMINATION:

GENERAL EXAMINATION

Head : NormocephalHair : black, normal distributionFace : symmetric, deformity (-)Eye : pale conjunctiva -/-, icteric sclera -/-,.ENT : nomotia, normosepta, rhinorrhea (-), otorrhea (-), blood (-), pharyngeal hyperemic (-), T1-T1 Mouth : pale mucosal (-), dry mucosal (-)Neck : no lymph node enlargement

Chest

LungInspection : Normal chest shape, symmetrical move in

static and dynamic, venectation (-), spider naevi (-), intercostal retraction (-)

Palpation : Tactile fremitus in both field are symmetric, symmetrical chest expansion, tendreness (-), mass (-)

Percussion : resonant in both field

Auscultation : vesicular breath sound without any ronchi/ wheezing/stridor.

Heart

Inscpection : ictus cordis unseen Palpation : ictus cordis palpable at ICS V mid-clavicle linePercussion Left margin : ICS V right linea sternalis Right margin : ICS V 1 finger from left mid-clavicle line Upper margin : ICS IV linea parasternal kiri Auscultation : 1st and 2nd heart sound regular, murmur (-), gallop (-)

Abdomen

Inspection : flat, scar (-), caput medusa (-), mass (-).

Ausculatation : bowel sound (+)

Percussion : tympanic in all field

Palpation : supple, epigastric and suprapubic tenderness (+), unpalpable liver and spleen, massa (-), normal turgor

Extremities : warm acral, edema (-/-), cyanosis (-), CRT < 2 “,

3. LAB FINDING (14.30)Type Result Normal Value

11/06/2014 14.30

Hemoglobin 12.7 12-16 g/dL

Hematocrit 38 37-47 %

Erythrocyte 5.4 4,3-6,0 juta/μL

Leukocyte 15.390 4.800-10.800/μL

Trombocyte 301.000 150.000-400.000/μL

Diff count• Basophile• Eusinophile• Band• Segmented• Lymphocyte• Monocyte

01 479115

0-1%1-3%2-6%

50-70%20-40%22-8%

MCVMCH

6924

80-96 fL27-32 pg

MCHCPDW

3414.40

32-36 g/dL11.5-14.5 %

SGOT/AST 32 <35 U/L

SGPT /ALT 20 <40 U/L

Na 142 135-147 mg/dL

K 3.7 3.5-6.0 mmol/dL

Cl 108 95-105 mmol/dL

Immunoserology

WIDAL

S. Typhi O Negative Negative

S. Paratyphi AO Negative Negative

S. Paratyphi BO Negative Negative

S. Paratyphi CO Negative Negative

S. Typhi H Negative Negative

S. Paratyphi AH Negative Negative

S. Paratyphi BH Negative Negative

S. Paratyphi CH Negative v

CHEST XRAY APInterpretation• Cardiomegaly (-)

• Aorta elongation (-)

• Infiltrate (-)

Within normal limits

ECG (11/6/2014, 14:45)

• ECG

Interpretation:

Sinus tachycardia (120 bpm), QRS rate 77 ms, QRS axis: normoaxis, P wave: normal, PR interval 0.20s, QRS duration : 0.08s, ST depresi (-), T inverted (-).

III. RESUMEMs. G, 20 yo, came with upper abdominal pain since 5 hour before admission. Patient complained of upper abdominal pain, headache, fever, fatigue, nausea and vomiting. The pain was persistent. Localized at upper and also lower abdomen. The pain is not related to eat, menstruation, defecation, and urination. She only vomit once in the morning, containing food. There was no diarrhea, constipation, and faeces changes (normal consistency, no blood, and no mucus). She feels to urinating more often and waking from sleep to urinate. There was no urine changes. She has fever since last night. She admit that she had a sexual intercourse last month and history of vaginal discharge with yellow color and bad smell last week.

Physical Examination: epigastric and suprapubic tenderness

Lab: leukocyte (19.360)

IV. PROBLEM LIST1. Dyspepsia Syndorme e.c Functional Dyspepsia

2. Susp. UTI e.c bacterial infection

1. Dyspepsia Syndrome e.c Functional dyspepsia

Anamnesis:

upper abdominal pain, nausea, vomiting, heartburn (symptoms of dyspepsia), Pain or burning localized to the epigastrium of at least moderate severity, at least once per week, The pain is intermittent, Not generalized or localized to other abdominal or chest regions. These symptom has been going for almost 4 months. There is no pain related with food

Physical Examination: Epigastric tenderness

FGID CRITERIA BASED ON ROME III DIAGNOSTIC CRITERIA FOR FUNCTIONAL GASTROINTESTINAL DISORDERS :

Planning of treatment:

o Lifestyle changes: eat regular meal, avoid smoking, or drinking alcoholoOndancentron 3 x 4 mg i.voOmeprazole 1 ampule (40mg) / 12 hours

2. Susp UTI ec bacterial infection

Anamnesis:

• Lower abdominal pain suprapubic pain

• Fever.

• Increased of frequency and urgency of urinating urinating more often and waking from sleep to urinate. • Bad Hygiene (history of vaginal discharge) risk factor

• History of sexual intercourse risk factor

Physical examination:

Fever (37.9oC), Suprapubic tenderness

Laboratorium finding: leukositosis > 19.390

Planning of diagnostic: Complete urinlaysis, urine HCG level test, Urine culture

Planning of treatment: Paracetamol 3 x 500mg p.o, Ceftriaxone 1 x 2 gr i.v

DIAGNOSIS BASED ON UROLOGICAL INFECTION GUIDELINE 2013 (EUROPEAN UROLOGY ASSOCIATION)

VI. PLANNING

Diagnostic Plan

1. Complete urine test2. Urine HCG test3. Urine cultures

Treatment Plan

1. IVFD RL 500 cc + 1 amp of omeprazole / 8 hours.

2. Ondansentron 3 x 4 mg3. Paracetamol 3 x 500 mg i.v4. Ceftriaxone 1 x 2 gr i.v5. Education: eat regular meal, avoid smoking, or

drinking alcohol

VII. PROGNOSIS

Quo ad vitam : bonam

Quo ad functionam : bonam

Quo ad sanationam : bonam

THANKYOU