A.

IDENTITY
Name : Ny. R
Birth date : January 1th 1944
Age : 73
Address : tanjung Priok . Jakarta Utara
Religion : Islam
Education : SLTP
Job : IRT
No.MR : 00-85-51-72
Date of admission : April 16th 2017
Date of examination : April 16th 2017

B. ANAMNESIS
Main Concern (AUTOANAMNESIS):

Abdominal pain since the night before

Medical History:

Abdominal pain radiating to epigastric region, a night long

fever,headache, nausea, vomit is note present. Normal urine
presentation, declining appetite has been presented since a few days
ago, defecation hasnt been done today.

Past Illnesses:

1. Hypertension, diabetes mellitus, high levels of uric acid : (+)

2. Hepatitis, transfusion history : (-)
C. PHYSICAL EXAMINATION
a. General status
General condition : Severe ill
Awareness : Composmentis
Height : 160 cm
Weight : 75 kg

b. Vital Status

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 BP : 130/80 mmHg
Pulse : 120 x/minute
RR : 54 x/minute
Suhu : 39 C
c. Physical examination
1. Head : Normocephal
2. Eyes :
Sclera : icteric +/+
conjungtiva : anemis -/-
Pupils : 3mm-3mm, isokor
3. Ears : Normal shape, no bleeding
4. Nose : Normal shape

5. Mouth :
Cyanosis : (-)
Lips : dry
Tongue : no dirty
6. Neck :
Faring : no hyperemia
Tonsil : T1-T1
Tyroid : normal
KGB : normal

7. Thoraks
Inspection : Symmetric when breathing , no retraction,
ictus cordis is not visible
Palpation : mass (-), tactile fremitus +/+

Percussion : sonor left = right

Auscultation : cor (regular s1 = s2, murmur -, gallop
-)
Pulmo (vesicular +/+, ronkhi -/-, wheezing -/-)
8. Abdomen

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 Inspection : convex, destention (-)
Palpation : Epigastric Pain, hepar 10 cm under arcus
costae and 5 cm under sacrum, hard
consistency, blunt edge, no nodularity
Percussion :The entired field of tympanic abdomen,
shifting dullness(-)
Auscultation : normal

9. Ekstremities
Cold , capillary refill time < 2 second, edema(-)

D. LABORATORY EXAMINATION
HEMATOLOGY (16/04/2017 11.05 )
Examination Result Unit Normal
value
Hb 14.5 g/dl 11.7 - 15.5
Leukosit 8.50 103/L 3.60 11.00
Hematokrit 43 % 35 47
Trombosit 204 103/L 150 - 440
Eritrosit 5.23* 106/L 3.80 5.20
MCV/VER 82 fL 80 100
MCH/HER 28 pg 26 34
MCHC/KHER 34 g/dl 32 36
SGOT (AST) 138* U/L 10 31
SGPT (ALT) 329* U/L 9 - 36
Ureum Darah 30 mg/dl 10-50
Kreatinin 0.8 mg/dl <1.4
darah
Na darah 137 mEq/L 135-147
K darah 3.2 * mEq/L 3.5-5.0
Cl darah 104 mEq/L 94-111
GDS 485 mg/dl 70 -200
Bilirubin total 11.8* mg/dL <1.0
Bilirubin 8.9* mg/dL <0.3
Direct
Bilirubin 2.9* mg/dL <0.8
indirect

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RONTGEN 16/04/2017)

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5
Kesan Ro Thorax:
Cardiomegali, Atherosklerosis aorta, Bronchopneumonia duplex

EKG 16/04/2017

EKG 17/04/2017

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AGD (17/04/2017 09.05)
Temperatur 36.0
Ph 7.407 7.370 7.450
pCO2 21.0 mmHg 33 44
pO2 66.4 mmHg 71 104
Saturasi O2 93.4 % 94.00 98.00
HCO3 13.4 mmol/L 21 28
BE (ecf) -11.5 mmol/L -2.00 - +3.00
BE (B) -8.9 mmol/L -2.4 -+ 2.3
Total CO2 14.00 mmol/L 23.00 27.00

(17/04/2017 10.40)
Amylase 31 U/L 25 115
Lipase darah 61 U/L 73 - 393

HEMOSTASIS (17/04/2017 13.32)

Masa
Protombin
Pasien 12.9* detik 9.3 11.4
Kontrol 10.0 detik
APTT
Pasien 68.7* detik 31.0 47.0
kontrol 33.0 Detik
Kadar
Fibrinogen
Fibrinogen 500* mg/dL 136 - 384
Kontrol 235
D-dimer 3900 g/L 0-300
Kuantitatif

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(17/04/2017 14.10)
Cl darah 106 mEq/L 94 -111
Ca darah 11.3* mg/dL 8.8 10.2
Mg darah 1.5* mg/dL 1.8 3.0
GDS 130 mg/dL 70 200
CRP Kuantitatif 120.0 Mg/L <6

Hematologi
Rutin
Hb 12.6 g/dL 11.7 15.5
Leukosit 37.26* 103 / L 3.60 11.00
Hitung Jenis
(Diff)
Basofil 0 % 01
Eosinofil 0* % 24
Netrofil Batang 8* % 3 -5
Netrofil Segmen 84* % 50 70
Limfosit 4* % 25 40
Monosit 4 % 2 -8
Hematokrit 39 % 35 -47
Jumlah 106* 103 / L 150 440
Trombosit
Eritrosit 4.54 106 / L 3.80 5.20
MCV/VER 85 fL 80 100
MCH/HER 28 Pg 26 34
MCHC/KHER 33 g/dL 32 36
Faal Hati
Protein total 8.2* g/dL 6.0 8.0
Albumin 3.6* g/dL 4.0 5.2
Bilirubin Total 8.6* mg/dL <1.0
Bilirubin Direct 8.2* mg/dL <0.3
Bilirubin 0.4 mg/dL <0.8
Indirect
Faal Ginjal
Ureum Darah 77* mg/dL 10 50
Kreatinin darah 3.9* mg/dL <1.4
Elektrolit
Na darah 142 mEq/L 135 147
K darah 3.9 mEq/L 3.5 50

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GDS 17/04/2017 (14.28)
Jam 05.00 69 mg/dL
Jam 08.00 132 mg/dL

AGD (17/04/2017 14.49)

Temperatur 38.5
Ph 7.324 7.370 7.450
pCO2 19.7 mmHg 33 44
pO2 184.7 mmHg 71 104
Saturasi O2 99.5 % 94.00 98.00
HCO3 10.3 mmol/L 21 28
BE (ecf) -15.9 mmol/L -2.00 - +3.00
BE (B) -12.9 mmol/L -2.4 -+ 2.3
Total CO2 10.90 mmol/L 23.00 27.00

KALSITONIN 17/04/2017 (18.17)

269 ng/mL <0.05

G. WORKING DIAGNOSIS
Shock sepsis ec Susp. Hepatitis
H. MANAGEMENT
Non-medikamentosa
1. bedrest
2. Observ Vital Sign
3. SC / 6 hour
4. Patients fasted
5. NGT
Medikamentosa
1. IGD :
Asering ( with blood set) loading 500 cc

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 Inj Ranitidin 1 amp
Inj Ondancentron 1 amp
Inj Ketorolac 1 amp
Paracetamol 1 tab

2. Konsul dr. Kuspudji, Sp.PD

Asering/12 hour
SMNC 1 x 2
Acran 2 x1
Ketorolac k/p

I.Follow Up

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j. PROGNOSIS
Quo ad functionam ad malam
Quo ad sanationam dubia
Qua ad vitam ad malam

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