Case Presentation

NABILA
Patient Identity
 Name : Mrs. SU
 Birth Date : September, 25th 1964
 Age : 52 years 6 months 16 days
 Gender : Female
 Address : Central Jakarta
 Nationality : Indonesia
 Religion : Islam
 Date of admission : April 11th 2017
 Date of examination: April 12nd 2017
History Taking
 Auto and Alloanamnesis from patient and her family on April 12nd
2015.

Chief complain:
• Vomiting 10 times a day

Additional complains:
• Nausea, abdominal pain, headache, diarrhea
History of Present Illness

 A 52 years old woman came in to the emergency room with vomiting 10

times a day since 8 hours before go to the ER. She also complain nausea,
abdominal pain, headache and diarrhea 3 times a day
 History Of Past Illness

 Hypertension since 20 years ago, gastritis 10 years

 Family History
 Hypertension (both parents)
Physical Examination
 Date : April 12nd 2017

 General Status

 General condition : mild ill

 Awareness : Delirium

 Blood Pressure : 150/100

 Pulse : 84 x/min, regular, full, strong.

 Breathing rate : 22x/min

 Temperature : 36,5oC (per axilla)

Systematic Physical Examination

Head Normocephaly, hair (black, normal distributon, not easily removed ) sign of
trauma (-)

Eyes Icteric sclera -/-, pale conjunctiva -/-, hyperaemia conjunctiva -/- , lacrimation
-/-, sunken eyes -/-, pupils 3mm/3mm isokor, Direct and indirect light
response ++/++
Ears Normal shape, no wound, no bleeding, secretion or serumen

Mouth
Lips: dry
Teeth: no caries
Mucous: moist
Tongue: Not dirty
Tonsils: T1/T1, No hyperemia
Pharynx: hyperemia

Neck Lymph node enlargement (-), scrofuloderma (-)

Thorax Symmetric when breathing , no retraction, ictus cordis is not visible
 Inspection:
 Palpation: mass (-)

 Percussion: sonor on left lungs

 Auscultation
Cor : regular S1-S2, murmur (-), gallop (-)
Pulmo: vesicular +/+, Wheezing -/- , Rhonchy -/-

Abdomen :
Inspection : normal

 Palpation : supple, liver and spleen not palpable, tenderness (+)

 Percussion: The entire field of tympanic abdomen, shifting dullness (-)

 Auscultation: bowel sound 15 times/min

Anus Not inspected

Extremities warm, capillary refill time < 2

second, edema(-)

Skin Good turgor

Laboratory Investigation Hematology (April 11th 2017)

Hematology Results Normal Value

Haemoglobin 13,1 g/dL 11,7 – 15,5 g/dL

Leukocytes 8.990/µL 3,600 – 11,000/µL

Hematocrits 37 % 35 – 47 %

Trombocytes 240.000/ µL 150,000 – 440,000/µL

Erythrocytes 4,62 million/µL 3,80 – 5,20 million/µL

Creatinine 1,5 mg/dL < 1,4 mg/dL

Laboratory Investigation Hematology (April 11th 2017)

Hematology Results Normal Value

Natrium 125 mEq/L 135 – 147 mEq/L

Kalium 3,2 mEq/L 3,5 – 5,0 mEq/L

Chloride 94 mEq/L 94 – 111 mEq/L

Blood Glucose 92 mg/dL 70 – 200 mg/dL

Working Diagnosis

 SOL
MANAGEMENT (April 11th 2017)

 IVFD Assering / 12 hours

 Ulsafat tab 3 x 1

 Flunarizin 10mg 1x1

 Amlodipin 5mg 1x1

 Rantin inj 2x1

 Ondancentron inj 3x1

MANAGEMENT (April 12nd 2017)

 NaCl 3% / 12 hours

 Ulsafat tab 3 x 1

 Flunarizin 10mg 1x1

 Amlodipin 5mg 1x1

 Rantin inj 2x1

 Ondancentron inj 3x1

 Lansoprazol 2 x 1

 Folic acid 2 x 1

 Phenytoin 3 x 1
PROGNOSIS

 Quo ad vitam : dubia

 Quo ad functionam : dubia
 Quo ad sanactionam: dubia