Mrs. N is a 35 year old woman who presents today complaining of abdominal pain.

She states that she experienced sharp pain in the epigastrium region of her abdomen
for four days. The pain comes and goes, with a duration that lasts for 1 hour. The pain
is exacerbated with drinking coffee, but she felt better after eating. She rates the pain
as 6/10. She tried to alleviate the discomfort by taking promag 6 hours ago. The pain
became less intense afterwards, but it worsens after a few hours. She states that she
occasionally experience similar epigastric pain since 20 years ago. She is not
nauseous and no vomitting. There were also no difficulties in defecating and
urinating. She has irregular dietary habit and always eat late. The last meal she had
was Indomie instant noodle.

Active Medical Problems

 Asthma, diagnosed during kindergarten years
 Similar occasional epigastric pain, since 20 years ago

Medications
 Salbutamol 1x daily

Surgical
 Cesarean section,

She has similar complaint of occasional abdominal pain since 20 years ago.
She has tried Promag and has been to the doctors before. The last abdominal pain was
1 month ago. She denies having DM, HTN, cholesterol and heart problems, however
the problems stated were never checked.

ROS
 Head and Neck : No complaints of headache, no changes in vision
 Respiratory system : No complaints of difficulty breathing, cough or cold
 Gastrointestinal system: No complaints of nausea, vomit, diarrhea, or bloating.
She complains of epigastric pain
 Genitourinary system : No complaints of dysuria. But there is change in urine
color (?)
  Muskuloskeletal system : No complaints of stiffness, cramps, or muscle aches.
 Neurological system : No complaints of weakness, numbness or
incoordination.

Social History
Mrs. N is a housewife who lives in Binong, together with her husband and 3 children.
Her children are aged 6, 9 and 12 yo. Her daily activities are mostly houseworks and
chores. She is not physically active, and her dietary habit is irregular. She tends to eat
late. She drinks black coffee 2 times daily. Aside from that, she likes to eat sour
foods, such as mangoes. She doesn't like sweet foods and occasionally eats spicy
foods. She doesn't smoke nor drink alcohol.

PE
TTV : BP 120/80
RR 12x / min
HR 80x / min
Temp 37 C

General : Alert, calm, well-developed women, habitus athleticus

Specific:

 HEENT :
 Head - Normocephaly and symmetric. No pain, no mass and no lesion were found.
 Eyes - Pupils equal, round and reactive to light, Extraocular movements intact.
Conjunctiva pink with no redness or exudates. Sclera without icterus. No lesions on
eyelids.
 Ear - External ears normal, no lesions or deformities. tympanic membranes intact.
cerumens are found in the canal. hearing grossly intact bilaterally.
 Nose - symmetric, no deformities on septum nasii. nostrils intact. no pain in
palpation. nasal mucosa normal. Concha is not hyperemia. cerumen is found along
the nose canal.
 Throat - lips is not cyanosis nor anemic, no karies, no lesion or ulcer in gums and
tongue. Pharynx is not hyperemic. Tonsil is T1.
 Neck - no swollen lymph nodes. thyroid is not palpable

 Thorax :
 Chest : symmetric, no pectus excavatum or carinatum, no lesion or color changes
found,
 Lungs : chest during static is symmetric, chest movement during dynamic is
symmetric, normal chest expansion and tactile fremitus, sonor percussion sound in
lung field, normal vesicular sounds are heard.
 Heart : ictus cordis is not seen, Normal S1, S2; no additional sounds.

 Abdominal:
 The abdomen is soft, flat, symmetrical without distention, no scar, no lesion, no
changes in color; dam steifung, dam contour, caput medusae and herniation of
umbilical are not found. Bowel sounds are normal, 5 times/min. No masses are noted;
no splenomegaly or hepatomegaly. liver span is 7 cm by percussion. Shifting dullness
negative. Pain in the epigastric region is noted during palpation. liver, spleen and
kidney are not palpable. murphy sign and CVA are negative. no pain in mcberney
pain during palpation

 Extremities : No cyanosis, clubbing, or edema are noted. No rash, lesions or

deformities. Warm and active.

 Neurological : reflexes are normal

 FIFE
 F : She feels sad
 I : She thinks that it is gastric problem
 F : The problem doesn't affect her life
 E : She expects to recover well.