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Departement of SURGERYPavilion shofa, 6th march 2013(14.00- 07.00 am)
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Identity
Name : Mr. RH Age : 37 YO
Address : Andanwangi street,
Sukomulyo Lamongan Occupation : Enterpreneur
Religion : Moeslim
Date : 06 March 2013 at 09.00 am
No. MR : 19.81.59
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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 feltNausea (-), vomit (-). This pain could reduce by
analgesic but about this 7 days its still pain.
Defecation and urination within normal limit. Fever(-).
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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 (+)
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Physical Examinations
General Appearance : weak
GCS : 456
Vital sign :
BP : 127/89 mmHg
Pulse : 80 bpm
RR : 22x/minutes
T : 36,8 C
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Physic Examinations
General appearance : weak
Head and neck :
Anemic -/icteric-/cyanosis-/dyspneu-
Thorax :
I : simetric bilaterally+
P : ICS normal
P : sonor/sonorA : ves/ves, rh-/-, whz-/-
RR : 20x/minute, spontan
Cor : S1 S2 single, M-, G-
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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
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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
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USG Abdomen
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Cholelithiasis
Assessment
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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
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Prognosis
Dubia ad bonam
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Education
Explain to the family about the condition of this
patient now, its disease, about itsexaminations, theraphy and intervention will
be done, and also about complication and
prognosis.
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