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• App surgery
29 years ago
• Hipertension
15 years ago • Amlodipin 5 mg
• Epigastrium tenderness
4 hours pre •
•
Radiating to the back (scapula)
pain continously
hospitalized • Neusea (-) vomiting (-)
• Emergency room
Sept,11 2016
at 2 pm
Physical Examination
Head and neck
Eye Anemis (-|-) Icterik (+|+)
Neck Cyanosis (-) Lymph node (N)
Thorax
Shape of chest D=S
Using accessory muscles/general respiratory effort
Inspect chest
(-)
Retraction (-)
Trakhea (middle)
Fremitus :
Palpation ( N / N)
( N / N)
Pulmonary ( N / N)
Identify
(sonor / sonor)
Percussion
(sonor/ sonor)
(sonor/ sonor)
Ves Wh Rh
+ + - - - -
Auscultation + + - - - -
+ + - - - -
Physical Examination
Inspect Ictus kordis can’t be evaluated
Palpation Ictus cordis (P)
Cor Cor Left Border= Mid clavicula Line ICS V Sinistra
Percussion
Cor Right Border= ICS IV PSL Dextra
Auscultation S1 S2 single, regular, murmur (-), gallop (-)
Abdomen
Inspect Flat (+), scar (+)
Auscultation BS (+) Normally
epigastrium tenderness(+) , Hephatomegaly (-)
Palpation
Murphy sign (+)
Percussion Timpani , Ascites (-)
Extremities
Superior warm, cyanosis (-), edema (-)
A
Obs icteric Obs icteric d.3 Susp choledocolithiasis
Dyspepsia Susp cholelitiasis
Susp cholelitiasis
Day 1 Day 3 Day 4
USG abdomen
MSCT abdomen with
(Cholelitiasis suspect contras
IHBD stone with mild
widening CBD)
Day 9 Day 10 Day 19 Day 24
(19/9/2016) (20/9/2016) (29/9/2016) (04/10/2016)
S Epigastrium Epigastrium Epigastrium Outpatient planning
tenderness tenderness tenderness
O Composmentis Composmentis Composmentis WBC: 7.68
GCS : E4V5M6 GCS : E4V5M6 GCS : E4V5M6 Hb: 12,3
BP: 130/80 RR:20 BP: 120/80 RR:22 BP: 130/80 RR:24 Bil T/D/I: 1,2/0,5/0,7
HR : 74 Temp:37,1 HR : 75 Temp:36,7 HR : 84 Temp:37,1 SGOT: 124
SGPT: 31
Icteric (-/-)
Murphy sign (-) Consult to surgeon
SGOT: 138
SGPT: 315
Bil T/D/I: 2,6/ 1,5/ 1,1
A Cholelithiasis with Cholelithiasis with Post Laparotomy
cholecystitis cholecystitis cholecystectomy
Day 9 Day 10 Day 19 Day 24
MSCT abdomen
(cholelithiasis
with
cholesistitis,
renal cyst
dextra, right
minimal pleura
effusion)
*
*
*
* Name : Mrs. M
* Age : 39 YO
* Sex : Female
* Address : Jl. Soekarno Hatta, Loa janan
* Religion : Islam
* Work : civil worker
* Hospitalized : 18 September 2016
*
5 weeks ago
• Hospitalized with 18 September
• Hiperucemia
• Hospitalized the same 2016
• Cholestrol complaint
• icterus • Emergency Room
• App surgery • Abdominal • Abdominal tenderness
tenderness • Neusea + • Palpable mass in the
• Firstly, persistent vomiting + abdominal
pain 4 days
• Intermitten pain
• Gastroscopy
3 months ago • BNO
• ERCP
• USG abdomen • MRCP
• MSCT abdomen with
contras
2 weeks ago
Physical Examination
Head and neck
Eye Anemis (-|-) Icterik (-|-)
Neck Cyanosis (-) Lymph node (N)
Thorax
Shape of chest D=S
Using accessory muscles/general respiratory effort
Inspect chest
(-)
Retraction (-)
Trakhea (middle)
Fremitus :
Palpation ( N / N)
( N / N)
Pulmonary ( N / N)
Identify
(sonor / sonor)
Percussion
(sonor/ sonor)
(sonor/ sonor)
Ves Wh Rh
Auscultation
+ + - - - -
+ + - - - -
+ + - - - -
Physical Examination
Inspect Ictus kordis can’t be evaluated
Palpation Ictus kordis (P)
Cor Cor Left Border= ICS V MCL Sinistra
Percussion
Cor Right Border= ICS IV PSL Dextra
Auscultation S1 S2 single, regullar, murmur (-), gallop (-)
Abdomen
Inspect convex, scar (+)
Auscultation BS (+) Normally
epigastrium tenderness(+) , Hepatomegaly (-) mass
Palpation
(-)
Percussion Timpani , Ascites (-)
Extremities
Anemis (+/+)
Anemis (+/+) WBC: 30.0
Icteric (-/-) RBC: 3.68
Icteric (-/-)
Palpable mass in epigastrium Hb: 9,6
Palpable mass in epigastrium MCV: 77,3
quadran MCH: 26,1
quadran
MCHC: 33,7
Ht: 28,4
PT: 17,0 PLT: 511
INR: 1,47
A - Pancreas cyts Pseudocyts pancreas Pseudocyts pancreas
Cholelithiasis Cholelithiasis
*
Day 1 Day 2 Day 3
WBC: 17.8
RBC: 3.47
Hb: 8,7
MCV: 77,6
MCH: 25,1
MCHC: 32,3
Ht: 26,9
PLT: 506