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C3
A 64 year-old Male was admitted to R.D. Kandou
Hospital at C3 ward on 23 August 2017
Habit history :
Alkoholism (-), Smoking (-)
Family History
None experienced the same illness
General anamnesis ( review of system )
General : Nausea, poor appetite, fever
Skin : Yellow discoloration
Head and neck : -
Eye :-
Ear :-
Nose : -
Mouth and throat: -
Respiratory :-
Chest : -
Heart : -
Abdomen : Upper right abdominal pain,
Genitalia :-
Kidney : Deep yellow colored urine
Hematology :-
Endocrine :-
Musculosceletal :-
Physical Examination
GC: Moderate ill Sens : CM
C1:BP: 120/70mmHg, PR 88x/m, RR 20x/m, T 36,5C
ER :BP: 110/80mmHg , N 93x/m, RR 18x/m, T 36,3 C
BW 70 kg, BH 170 cm, BMI 24.2 kg/m2
Head : conj. anemic (-), scl. icteric(+),
Neck : JVP 5+0 cmH20, lymph nodes enlargement (-), thyroid (-)
Thorax :
Heart :
Insp : IC not visible
Palp : IC not palpable,
Perc : left border: ICS V midclavicullar line
right border: ICS IV parasternal line
Ausc : SI-II regular, murmur (-), gallop (-)
Physical examination
Lung : Insp : Symmetric
Palp : stem fremitus R = L
Perc : sonor +/+
Ausc : vesicular, ronchi -/-, wheezing -/-
Abd :
Insp : Flat
Palp : pain (+) in the right hypochondrium and epigastrium
region; Murphy sign(+)
Liver and spleen not enlarged
Perc : Tympanic in all regions, shifting dullness (-)
Ausc : Bowel sound (+) normal
Lab:
Hb 9.4
Ht 26,2%
MCH 34.3
MCHC 36
MCV 95.3
Anemia
Normochrom
Normocitic ec
GIT bleeding
dd/ renal
disease
Conclusion
Has been reported A 61 year-old man admitted to R.D.
Kandou Hospital at C4 ward on January 10th, 2016 at
04.10 with main complain Yellow discoloration of the
skin, from anamnesis, physical examination an
laboratory diagnosed with obstructive jaundice ec
suspect acute cholangitis, dd choledocholithiasis, dd
cancer of the head of the pancreas + Hypo Na+ Hypo K
+ Hyperuricemia
Prognosis
Ad Vitam : Dubia ad Malam
Ad Functionam : Dubia ad Malam
Ad Sanationam : Dubia ad Malam
Thank You