Departement of SURGERY

Pavilion shofa, 6th march 2013 (14.00- 07.00 am)

Identity
Name Age Address

: : :

Occupation
Religion Date No.

MR

: : : :

Mr. RH 37 YO Andanwangi street, Sukomulyo Lamongan Enterpreneur Moeslim 06 March 2013 at 09.00 am 19.81.59

Anamnesis
Chief complaint: abdominal pain Present illnes: Patient complained about his abdominal pain in Right Upper Quadrant since 7 days before hospitalized. The pain was reffered to his back. The pain was relaps in last one year. He felt Nausea (-), vomit (-). This pain could reduce by analgesic but about this 7 days its still pain. Defecation and urination within normal limit. Fever (-).

History or past illness : He had history of cholelithiasis about one year ago. Hypercholesterol denial Diabetes & hypertension denial History of liver disease (-)

History of family: - History of cholelithiasis (-)

-

History of sociality: High cholsterol Food consumption (+)

 Physical Examinations
General

Appearance : weak GCS : 456 Vital sign :

BP : 127/89 mmHg Pulse : 80 bpm RR : 22x/minutes T : 36,8 C

 Physic Examinations
General

appearance : weak Head and neck : Anemic -/icteric-/cyanosis-/dyspneu Thorax : I : simetric bilaterally+ P : ICS normal P : sonor/sonor A : ves/ves, rh-/-, whz-/RR : 20x/minute, spontan Cor : S1 S2 single, M-, G-

Abdomen : I : Flat, mass (-) P : Soefl, tenderness (+) RUQ, Murphy sign (+) P: Tymphani (+) A : Bowel Sound (+) Nomal, Met (-) Extremity : Dry and warm to touch CRT< 2 detik

Laboratory Findings Diff count: 0/0/66/10/4 Hematocrite: 43,9 % Hb 14,7 mg/dl LED : 11/23 Leukocytes : 8.600 Thrombocyte : 266.000 Alkali phospatase : 203 U/L Bilirubin direk : 0,22 mg% Bilirubin total 0,43 mg% SGOT/SGPT : 15/15 U/L Urea 19 mg/dl Serum creatinin 1 mg/dl Cholesterol 219 LDL Cholesterol 147, 1 mg/dl HDL Cholesterol 44,6 mg/dl Trigliserida 154 mg/dl BRG : 101

USG Abdomen

Clue and Cue

Man, 37 year-old Abdomnal pain RUQ History of cholelithiasis (+) Murphy sign (+) Vomit (-), nausea (-) USG abdomen : cholelithiasis 14 mm

Assessment

Cholelithiasis

Planning Dx : -

Planning Tx : Infus Asering 1500cc/24h Inj.Ketorolac Inj cefotaxim 3x1 g i.v Inj pantoprazole 2x1 i.v Inj ondansentron 3x8mg i.v Inj ranitidin 2x50 mg i.v c/ surgery pro cholesistecthomy

Prognosis
Dubia

ad bonam

Education
Explain

to the family about the condition of this patient now, its disease, about its examinations, theraphy and intervention will be done, and also about complication and prognosis.