Patient List

No Identity Admission to ER Diagnosis Planning

5. Ms. Arina Rofiqoh 12th May 2019 at Ulcerative Colitis Treatment from neurologist :
/Female/ 22 23.10 pm • IVFD RL 20 dpm
YO/1230529 • Inj ketorolac 30mg
• Inj Ranitidin 50mg
• Patient going to
outpatient departement
 5. Ms. Arina Rofiqoh /Female/ 22
YO/1230529/ admitted 12th May 2019
at 23.10 pm
Chief Complain: Pain in stomach
History taking:
Patient came with complaint about pain all over the stomach since 1 day before admitted to Ulin
hospital. The characteristic of abdominal pain is appeared suddenly, sharp, and intermittent. The abdominal
pain become heavier when she had eaten and done her activity, the pain decreased after she taking a rest.
Patient also complained bloody defecation with black stool and the watery consistency for 1 month
and stopped 1 week ago because she took a medicine from Pelaihari hospital.
Patient has history of laparoscopy 5 months before administered and Colonoscopy 4 months before
administered.
History of past illness: colitis 2 years before administered, appendicitis & appendectomy in 2012, typhoid
fever 1 week before administered
 Vital Sign
BP : 140/80 mmHg
RR : 20 tpm
HR : 96 bpm, weak and regular pulse
Temp : 37.2oC
VAS : 5/10
SpO2 : 98% with O2 supply 4 lpm
Physical Examination
Head/Neck • pale conjungtiva (-/-), sclera icteric (-/-), pupil equal, enlargement lymph node (-)

• I : symmetric respiratory movement, retraction (-), bruise (-)

Chest • P : sonor at all lung fields
• A : vesicular breath sound, rhonchi (-), wheezing (-)
• I : distension (-) , scar (+) et region right lower quadrant, pus (-), mass (-), inguinal
mass (-)
• A : bowel sound (+) Increase, 30x/minute
Abdomen • P : tenderness (+) in all region Abdomen, defance muscular (-), liver / spleen / mass
hard to evalutaed
• P : Tymphani

Extremities • warm extremities (-), parase (-), edem (-)

 Digital Rectal Examination
I : haemorrhoid (-), laceration (-), mass (-), fistle (-)
P:
- Spincter ani tone : normal limit
- Mucosa was not slippery
- Ampulla was not collapse
- Mass (-)
- Prostate : symmetries, soft, upper pole was palpated, median
sulcus was concave, nodule (-)
- Handscon : Feces (+), blood (-)
Clinical Picture
USG Abdomen 04/12/2018
MSCT 11/12/2018
Colonoscopy 16/01/2019
 Laboratory Finding
Examination Result Normal Value
Hemoglobin 11,2 12,00-16,00 g/dl
Leukosit 6,5 4,0-10,5 ribu/ul
Eritrosit 4,05 3,90-5,50 juta/ul
Hematokrit 33,2 37,00-47,00 vol%
Trombosit 277 150-450 ribu/ul
RDW-CV 13,2 11,5-14,7 %
MCV 82,0 80,0-97,0 fl
MCH 27,7 27,0-32,0 pg
MCHC 33,7 32,0- 38,0 %
Gran% 68,7 50 – 81
Limfosit% 23,7 20 – 40
MID % 7,6
Gran# 4,50 2,5 – 7
Limfosit# 1,50 1,25 – 4
 Laboratory Finding
Examination Result Normal Value
Random Blood Glucose 87 <200.00 mg/dl
SGOT 23 5-34 u/l
SGPT 10 0-55 u/l
Ureum 16 10-50 mg/dl
Creatinin 0,59 0.6-1.2 mg/dl
Natrium 140 135-146 mmol/L
Kalium 4,7 3,4-5,4 mmol/l
Chlorida 107 95-100 mmol/l
Diagnosis
Ulcerative Colitis
 Management

• Treatment from ER
– IVFD RL 20 dpm
– Inj Ketorolac 30mg
– Inj Ranitidin 50mg
– Patient going to outpatient
departement
Durante Operation