Christian University of Indonesia June, 12 th 2014 TEAM 4 Ms. MZ (20 YO) Findings Assesment Therapy Planning Nausea Vomit Weakness Loss of appetite Constipation Appearance : moderate illness, GCS E4V5M6, BP : 110/80 mmHg, PR : 88x/min, RR : 32x/min, T : 36,6C Eye : hyperemic conjunctiva -/-, icteric sclera -/- THT : normal Mouth : coated tongue -, tremor - Neck : lymph nodes not enlarge, JVP : 5-2 cmH2O Thorax Ins : symmetric Pal : vocal fremitus sound symmetric Per : symmetric sonor sound Aus : basic sound of breath vesicular, wheezing -/-, ronchi -/-. Heart sound I&II regular, murmur -, gallop - Abdominal Ins : flat Aus : bowel sound 4x/min Pal : pain on hypochondriac dex&sin, epigastric, lumbar dex&sin, and umbilical region, liver and spleen not palpable enlarged Per : percution pain +
X X X
X X X
Extremities : warm acral, CRT < 2, edema
LAB FINDING Hemoglobin : 13,4 g/dl Hematokrit : 37,8 % Leukocytes : 7800 /ul Plateletes: 221.000 /ul Na 142 mmol/L K 3,6 mmol/L Cl 104 mmol/L Acute Gastritis Pro Hospitalized Diet : Rice porridge IVFD : I futrolit II RL / 24hrs Mm/ Omeprazol drip 2x1 Inpepsa 3x2 Ondancentron 2x4mg Rebamipid tab 2x1 - H2TL Subjective Data Name : Ms. Miftahul Z CM : 09.66.05.00 TC : Thursday, June 12 st 2014 CC : Abdominal Pain
Anamnesis Main symptom : Abdominal pain Additional symptom :Nausea Vomit Weakness Loss of appetite Constipation
Patient came with Abdominal pain since 2 days ago. She felt intermittent abdominal pain. The other complain were nausea and vomit. Patient vomit 5 times already and vomit consists of water and food. Beside that, the patient has not defecate since 3 days ago. Past Medical History and Treatment denied
Family History denied
Social History denied Objective Data Appearance : Moderate Illness GCS E4M6V5 BP : 110/80 mmhg, RR: 32x/ minute, T : 36,6 o C Pulse : 88x/minute. Eye: Pale conjunctiva -/- , sclera icteric -/- Ear, Nose, throat : normal Mouth : coated tongue -, tremor - Neck : lymph nodes not enlarge, JVP : not distended
Thorax. I : symmetrical, non-visible ictus cordis Pal: symmetrical vocal fremitus, ictus cordis : unpalpable Per: Sonore, cardiac englargement (-) Aus: Vesical basic breath sound, ronchi (-), wheezing(-). Normal heart sound, gallop (-), murmur (-) Abdomen. I : flat Aus : bowel sound (+) 4x/minute Per :timpani, percussion tenderness (+) Pal : abdominal tenderness (+), liver and spleen enlargement (-) Extremity - Warm - Capillary refilling time <2 second - Edema (-)
Anesthesia & Analgesia Volume 114 Issue 2 2012 (Doi 10.1213/ane.0b013e31823b2602) Zhang, Bin Tian, Ming Zhen, Yu Yue, Yun Sherman, Janet Zhen - The Effects of Isoflurane and Desflurane On Cogn