The patient is a 20-year-old female who presented with upper abdominal pain, headache, fever, nausea, and vomiting. Physical examination found epigastric and suprapubic tenderness. Laboratory tests showed leukocytosis. The patient is assessed as having dyspepsia syndrome likely functional dyspepsia and suspected urinary tract infection. The treatment plan includes IV fluids, antibiotics, antiemetics, and analgesics as well as lifestyle counseling. The prognosis is good for life, function, and healing.

1. Coass: Fathin and Laresi
Resident: dr. Martua
General practitioner: dr. Ananita
Supervisor : dr Soroy Lardo SpPD FINASIM
Department Of Internal Medicine
Indonesia Army Central Hospital Gatot Seobroto
DUTY REPORT
THURSDAY, 12 JUNE 2014

2. PATIENT RECAPITULATION
In patient
3rd floor : 2 patient
4th floor : 2 patient
5th floor : 2 patient
Ms. Gadis,20 y.o, with dyspepsia and suspect UTI
6th floor : 2 patient
 Out patient : 0 patient
 Death : 0 patient

3. I. PATIENT IDENTITY
Patient Initial : Ms. G
Date of Birth : March 5, 1994
Age : 20 yo
Sex : Female
Address : Dsn Mrogian RT 01/02 Dandang Gendis Pasuruan, East Java
Marital Status : Single
Medical Record number: 714374
Date of admission : June 11, 2014.

4. II. BASIC DATA
1. ANAMNESIS (Autoanamnesis)
Chief complaint: Patient came with upper abdominal pain
since 5 hours before admission.

5. HISTORY OF PRESENT ILLNESS :
• Patient complained of upper abdominal pain, headache, fever, fatigue, nausea and
vomiting.
• The pain was persistent. Localized at upper and also lower abdomen. The pain is not
related to eat, menstruation, defecation, and urination.
• She only vomit once in the morning, containing food.
• There was no diarrhea, constipation, and faeces changes (normal consistency, no blood,
and no mucus).
• She feels to urinating more often and waking from sleep to urinate. There was no urine
changes.
• She has fever since last night
5 hour before admission

6. • No history of gastric contain reflux, any acid taste in her mouth, or hoarseness.
• There is no referred pain from stomach to right quadrant of abdomen spreading to
shoulder and back
Diet history:
• She has bad appetite, only eat twice a day, small portion and early satiated.
• 1 week before admission she noticed a vaginal discharge, yellow color, bad smell.

7. • She used to have stomach problem before. She already went to the doctor
and consumed Antacid without any improvement.
• There is no history of surgery or hospitalization before
HISTORY OF PAST ILLNESS :

8. HABITS:
• She neither smoking nor drinking.
• She never consume any painkiller drugs (aspirin, nsaid; ibuprofen,naproxen)
• History of sexual intercourse (+)

9. TREATMENT HISTORY:
• Antacid (Mylanta, Promag)
• No one in her family who has any similar problem.
• No history of Diabetes Melitus, Hypertension,and allergic.
FAMILY HISTORY:

10. Physical Examination
•General state : Moderate illness
•Consciousness : Compos mentis
•Nutritional State : Well-nourished
Vital Sign
•Blood pressure : 127/71 mmHg
•Pulse : 80 x/mnt, regular.
•Respiratory rate : 22 x/mnt, thorakoabdominal, kussmaul breathing (-)
•Temperature : 37.9 ⁰C
•Body weight : 48 kg
•Body Height : 150 cm
•BMI : 21,8 (normoweight)
PHYSICAL EXAMINATION:

11. GENERAL EXAMINATION
Head : Normocephal
Hair : black, normal distribution
Face : symmetric, deformity (-)
Eye : pale conjunctiva -/-, icteric sclera -/-,.
ENT : nomotia, normosepta, rhinorrhea (-), otorrhea (-), blood
(-), pharyngeal hyperemic (-), T1-T1
Mouth : pale mucosal (-), dry mucosal (-)
Neck : no lymph node enlargement

12. Chest
Lung
Inspection : Normal chest shape, symmetrical move in static and
dynamic, venectation (-), spider naevi (-), intercostal retraction (-)
Palpation : Tactile fremitus in both field are symmetric, symmetrical
chest expansion, tendreness (-), mass (-)
Percussion : resonant in both field
Auscultation : vesicular breath sound without any ronchi/
wheezing/stridor.

13. Heart
Inscpection : ictus cordis unseen
Palpation : ictus cordis palpable at ICS V mid-clavicle line
Percussion
Left margin : ICS V right linea sternalis
Right margin : ICS V 1 finger from left mid-clavicle line Upper margin :
ICS IV linea parasternal kiri
Auscultation : 1st and 2nd heart sound regular, murmur (-), gallop (-)

14. Abdomen
Inspection : flat, scar (-), caput medusa (-), mass (-).
Ausculatation : bowel sound (+)
Percussion : tympanic in all field
Palpation : supple, epigastric and suprapubic tenderness (+),
unpalpable liver and spleen, massa (-), normal turgor
Extremities : warm acral, edema (-/-), cyanosis (-), CRT < 2 “,

15. 3. LAB FINDING (14.30)Type Result NormalValue
11/06/2014 14.30
Hemoglobin 12.7 12-16 g/dL
Hematocrit 38 37-47 %
Erythrocyte 5.4 4,3-6,0 juta/μL
Leukocyte 15.390 4.800-10.800/μL
Trombocyte 301.000 150.000-400.000/μL
Diff count
• Basophile
• Eusinophile
• Band
• Segmented
• Lymphocyte
• Monocyte
0
1
4
79
11
5
0-1%
1-3%
2-6%
50-70%
20-40%
22-8%
MCV
MCH
69
24
80-96 fL
27-32 pg
MCHC
PDW
34
14.40
32-36 g/dL
11.5-14.5 %

16. SGOT/AST 32 <35 U/L
SGPT /ALT 20 <40 U/L
Na 142 135-147 mg/dL
K 3.7 3.5-6.0 mmol/dL
Cl 108 95-105 mmol/dL

17. Immunoserology
WIDAL
S. Typhi O Negative Negative
S. Paratyphi AO Negative Negative
S. Paratyphi BO Negative Negative
S. Paratyphi CO Negative Negative
S. Typhi H Negative Negative
S. Paratyphi AH Negative Negative
S. Paratyphi BH Negative Negative
S. Paratyphi CH Negative v

18. CHEST XRAY AP
Interpretation
• Cardiomegaly (-)
• Aorta elongation (-)
• Infiltrate (-)
Within normal limits

19. ECG (11/6/2014, 14:45)

23. • ECG
Interpretation:
Sinus tachycardia (120 bpm), QRS rate 77 ms, QRS axis: normoaxis, P
wave: normal, PR interval 0.20s, QRS duration : 0.08s, ST depresi (-), T
inverted (-).

24. III. RESUME
Ms. G, 20 yo, came with upper abdominal pain since 5 hour before admission.
Patient complained of upper abdominal pain, headache, fever, fatigue, nausea
and vomiting. The pain was persistent. Localized at upper and also lower
abdomen. The pain is not related to eat, menstruation, defecation, and urination.
She only vomit once in the morning, containing food. There was no diarrhea,
constipation, and faeces changes (normal consistency, no blood, and no mucus).
She feels to urinating more often and waking from sleep to urinate. There was no
urine changes. She has fever since last night. She admit that she had a sexual
intercourse last month and history of vaginal discharge with yellow color and bad
smell last week.
Physical Examination: epigastric and suprapubic tenderness
Lab: leukocyte (19.360)

25. IV. PROBLEM LIST
1. Dyspepsia Syndorme e.c Functional Dyspepsia
2. Susp. UTI e.c bacterial infection

26. 1. Dyspepsia Syndrome e.c Functional dyspepsia
Anamnesis:
upper abdominal pain, nausea, vomiting, heartburn (symptoms of dyspepsia), Pain
or burning localized to the epigastrium of at least moderate severity, at least once
per week, The pain is intermittent, Not generalized or localized to other abdominal
or chest regions. These symptom has been going for almost 4 months. There is no
pain related with food
Physical Examination: Epigastric tenderness

27. FGID CRITERIA BASED ON ROME III DIAGNOSTIC CRITERIA
FOR FUNCTIONAL GASTROINTESTINAL DISORDERS :

29. Planning of treatment:
oLifestyle changes: eat regular meal, avoid smoking, or drinking alcohol
oOndancentron 3 x 4 mg i.v
oOmeprazole 1 ampule (40mg) / 12 hours

30. 2. Susp UTI ec bacterial infection
Anamnesis:
• Lower abdominal pain suprapubic pain
• Fever.
• Increased of frequency and urgency of urinating  urinating more often and waking from sleep to
urinate.
• Bad Hygiene (history of vaginal discharge)  risk factor
• History of sexual intercourse  risk factor
Physical examination:
Fever (37.9oC), Suprapubic tenderness
Laboratorium finding: leukositosis > 19.390
Planning of diagnostic: Complete urinlaysis, urine HCG level test, Urine culture
Planning of treatment: Paracetamol 3 x 500mg p.o, Ceftriaxone 1 x 2 gr i.v

31. DIAGNOSIS BASED ON UROLOGICAL INFECTION GUIDELINE 2013
(EUROPEAN UROLOGY ASSOCIATION)

32. VI. PLANNING
Diagnostic Plan
1. Complete urine test
2. Urine HCG test
3. Urine cultures
Treatment Plan
1. IVFD RL 500 cc + 1 amp of omeprazole / 8
hours.
2. Ondansentron 3 x 4 mg
3. Paracetamol 3 x 500 mg i.v
4. Ceftriaxone 1 x 2 gr i.v
5. Education: eat regular meal, avoid smoking, or
drinking alcohol

33. VII. PROGNOSIS
Quo ad vitam : bonam
Quo ad functionam : bonam
Quo ad sanationam : bonam

34. THANKYOU