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Guiding lecturer : Dr. Irwin Sp.PD By: Noor Ain bt Mohd Hariri
Name: Mrs. E
Religion: Islam
Ethnic: Sunda
Clinical history
Chief complaint
Burning-pain especially on upper stomach
Additional complaint
Mrs E come to the emergency unit,Hospital Karawang on Saturday night,6th October 2012 because of burning pain in her stomach.Besides,shes feeling weak and fatigue. She started feeling weak 2 days before,without any cause.From that point,she started to loss her appetite.On Thursday she drank coconut water,ate mungbean soup and ate a lot of green,unripe mangoes.
On Friday however,her stomach started feeling burning-pain,especially on upper stomach.She had diarrhea twice.She felt extremely weak after that, and her head hurts especially on the forehead.She also feeling nausea and vomiting water.On that instance she felt heartburn and feeling regurgitation in her throat and behind her nose. The burning sensation only presence after she ate and last a few minutes.Afraid that she might throw up,she ate only 2 spoons of porridge on Friday and ate nothing on Saturday.
After admitted in the ward, she never diarrhea, vomiting,and only have mild burning pain and headache. Overall,her condition becomes better and she regain her appetite.
Seldom excercise
She does not taking any drugs to relieve her pain.Going to the hospital is her first attempt to cure her illness.
Vital sign
RR: 16x/m
Pulse: 80x/m
Head
Eyes Ears Nose
Normocephali Pupil isokor, CA -/-, SI -/ Normotia, secrete-/-, serumen-/septum deviation (-), secrete -/-, concha normal, mucosa not hyperemic dry mouth (-), normal papil,mucosa hyperemic (-), teeth caries (-)
Mouth
Throat Neck
Lung
Inspection : Symmetrical Palpation : Equal vocal fremitus Percussion : Sonor Auscultation : Vesicular breath sound in both lung, no ronchi and wheezing
Heart
Inspection : Ictus cordis is invisible Palpation : Ictus cordis is palpable at 5th ICS LMCS Percussion : No enlargement of the heart Auscultation: Regular I - II heart sound no murmur and gallop
Inspection Palpation
Percussion
Auscultation
Warm acrals
+
-
+
-
Edema
Patient result
10,5 g% 6,400/uL 171.000 32 % 71 mg/dl
Normal range
12 17 g% 5000-10.000/uL 150.000-450.000 37-48 % 80-140 mg/dl
Ureum
Creatinine
21,9 mg/dl
0,82 mg/dl
10-45 mg/dl
0.4-1.5 mg/dl
Patient result
Normal range
GDS
124 mg/dl
80-140 mg/dl
Patient result
Normal range
GDS
133 mg/dl
80-140 mg/dl
Symptoms
Signs
Burning-pain especially on upper Pain present on stomach palpation at all abdomen Heartburn region especially Nausea Epigastric Regurgitation Loss of appetites Headache Muscle weakness
Achalasia Stenosis esophagus Gastritis Tumour esophagus Duodenum ulcer Peptic ulcer
Endoscopy
Medications
Non-medications
Avoid sour,spicy,fatty foods Eat meals in small portions Dont lie down after eating Elevate bed
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