Morning Report

th
21 December
2015

Patient identity

Name

: SHK

Gender

: Female

Age

: 24 y.o

Address

: Jl. Sempati Tuban

Religion

: Islam

Marriage

: Married

Occupation

: not worked

DoA

: 21th February 2016

Examination date : 21th February 2016

Anamnesis
Chief Complaint : epigastric pain

Patient come with complaint of epigastria pain since

yesterday evening (20 Feb 2016). The epigastrial pain
came suddenly, and felt like stabbed. The pain is steady
and also felt on back of the body. The pain increasing when
supine, and relieved if patient in sitting position. The
patient tried to give antacids, but there is no effect on
pain.

Patient also got nausea and vomit when the epigastrial

pain came.It worsen when patient tried to eat or drink.
Patient had vomit 3 times, with volume around 100 ml. The
vomit contain food that had been eaten

Fever (-),Flatus(+), melena (-),

Past History

History of gastritis since 5 years ago.

Family History

There is no member of family patient who has the same

complaint. History of DM, hypertension, heart, liver, and
kidney disease in family was denied by the patient.

Personal and Social History

Patient does not work. Patient never drink any alcohol.

Physical Examination
Present status:

General condition

: Moderately ill

Consciousness : E4V5M6

BP : 120/80 mmHg

Pulse rate

Resp. rate : 22 x/min

VAS: 3

Axillary temp. : 36,0o C

Weight : 55kg

Height : 155 cm

BMI : 22.89

: 88 x/min

General Status

Eye : anemic -/-, ikt -/-, pupillary reflexes +/+ isokor

ENT : Tonsil T1/T1, hyperemis (-)

Neck : JVP PR +0 cm H2O

Thorax : symmetrical

Cor :

: ictus cordis unseen

Pal

: ictus cordis palpable in MCL ICS 5

Per

: UB : ICS II
RB : right PSL
LB : ICS 5 MCL sinistra

Aus: S1S2 Single Regular, Murmur(-)

Lung:

: Symetrical on static and dinamic

Pa

: Vokal Fremitus N/N

Per

: sonor on both lung

Aus

: ves +/+, wh-/-, rh-/-

Abdomen :

: Distention (-)

Aus

: Bowel sound normal

Pal

: Liver/spleen
unpalpable,tenderness (+) on left
upper kuadran

Per

: Tympany(+), CVA pain (-)

Extremeties : Warm
+/+

-/-

+/+

Edema -/-

Supporting Examination
Parameter

Hasil

Unit

Nilai Rujukan

Keterangan

WBC

24.9

x10 /L

4,10 11,00

%NEU

91.25

47,00 80,00

%LYM

5.88

13,00 40,00

%MONO

2,41

2,00 11,00

%EOS

0,03

0,00 5,00

%BASO

0,43

0,00 2,00

RBC

4,75

x106/L

4,00 5,20

HGB

13,81

g/dL

12,00 16,00

HCT

44,15

36,00 46,00

MCV

92,99

fL

80.00 100.00

MCH

29,09

Pg

26,00 34,00

MCHC

31,28

g/dL

31.00 36.00

RDW

11,87

11,60 14,80

PLT

335,1

x103/L

140.00 440.00

Parameter

Hasil

Unit

NilaiRujukan

Keterangan

SGOT

14

U/L

11,00 27,00

SGPT

12,7

U/L

11,00 34,00

BS Acak

111

mg/dL

70,00-140,00

BUN

11

mg/dL

8.00 23.00

Creatinin

0.61

Mg/dL

0.50 0.90

Na

138

Mmol/L

136- 145

3.51

Mmol/L

3.50 5.10

amilase

12421

U/L

25-120.00

Lipase

1233

U/L

13-60

Assesment

Pancreatitis Akut

Planning
Therapy

Hospitalized

O2 nasal 4lpm

Insert NGT (Refused)

Fasting

Petidine 25 mg IM (if pain )

IVFD NaCL 0,9%, 20 drip/menit

Cefoperazone 2x1 gram IV

Antasida syr 3xCI PO

Planning Diagnosis

USG Abdomen

BOF

Lipid profile

Bilirubin

Monitoring

VS

Complaint

Amilase,lipase, @ 3 days