No.

Name : Mr. I Sex : Female

Age : 40 years No. Reg : 653029

Main complaint : Abdominal distention

History taking : The complaint had been apparent for 1 week. It started in
the small size and now become bigger and felt pain. There
were no events of vomiting and fever before.

Defecation : Normally
Micturation : Normally
 Physical Examination

General Conditions:
Moderate illness/well nourished/composmentis

Vital sign:
BP : 110/80 mmHg
PR : 84x/mnt, regular, adequate.
RR : 20x/mnt.
T(Ax) : 36,9 °C
PHYSICAL EXAMINATION
Abdomen
I : Abdominal distended

A : Bowel sound normally

P : Tenderness (+), solid, warm

P : Tympani
Abdominal X-Ray
Abdominal USG
Abdominal CT Scan
Chest X-Ray
Laboratory Result
WBC : 12,4x 103 /μL

RBC : 4.13x 106/μL

HGB : 11.1g/dL

HCT : 34%

PLT : 488x 103/μL

CT / BT : 8’30”/3’30”

Blood Sugar : 120 mg/dl

Ureum : 27 mg/dl

Creatinin : 0,50 mg/dl

SGOT/SGPT : 42/78 u/l

WORKING DIAGNOSIS : Pancreatic Cyst

MANAGEMENT :  Apply IVFD

 Medicaments
 Consult to Senior Digestive Surgeon
advice : Conservative