A 20-year-old female patient presented with abdominal pain, nausea, vomiting, weakness, loss of appetite and constipation for 2 days. On examination, she had abdominal tenderness and normal vital signs except a heart rate of 88 beats per minute. Laboratory tests showed normal hemoglobin, leukocytes and electrolytes. She was assessed with acute gastritis and admitted to the hospital for intravenous fluids, antacids and antiemetics.
A 20-year-old female patient presented with abdominal pain, nausea, vomiting, weakness, loss of appetite and constipation for 2 days. On examination, she had abdominal tenderness and normal vital signs except a heart rate of 88 beats per minute. Laboratory tests showed normal hemoglobin, leukocytes and electrolytes. She was assessed with acute gastritis and admitted to the hospital for intravenous fluids, antacids and antiemetics.
A 20-year-old female patient presented with abdominal pain, nausea, vomiting, weakness, loss of appetite and constipation for 2 days. On examination, she had abdominal tenderness and normal vital signs except a heart rate of 88 beats per minute. Laboratory tests showed normal hemoglobin, leukocytes and electrolytes. She was assessed with acute gastritis and admitted to the hospital for intravenous fluids, antacids and antiemetics.
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 +
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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 (-)