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Name : Mr. M
Age : 52 years old
Admission : August, 7th 2017
DPJP : dr. Muh. Jabir, Sp.U
HISTORY TAKING
Main complaint : the right abdominal pain
Anamnesis :
The patient was refference from kolaka hospital with the complaint was a
right abdominal pain that going through the backside that he felt since 2
weeks ago. The pain come with an epigastric pain. Nausea (+), vomitting (-),
fever (-). The patient also have a pain when defecating and a black stool
with soft consistency. The urinating is normal.
He has a history of a nefrolithiasis operation at 2015.
PHYSICAL EXAMINATION
General State :
Moderate ill, conscious
Vital Sign :
BP : 150/90mmHg
RR : 20x/m
HR : 84x/m
T : 37,30c
GENERALIZED STATUS
GDS 89 mg/dl
PARAMETER RESULT