Abdominal Pain: By: Enno Elfandari

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ABDOMINAL PAIN

By : Enno Elfandari
IDENTITY

Name : Mr. ld salihin


Age : 65 years old
Adress : konawe
Occupation : Farmers
Admission : August, 6th 2017
DPJP : dr. Tedjo Arianto, Sp.B-KBD
HISTORY TAKING
Chief complaint : abdominal pain
the patient came with complaint a pain at the right abdominal
since about 4 days ago. The pain felt constantly. Nausea (+),
vomiting (-), fever (-). She has a good desire to eat. There is not
weight decrease. Defecating and urinating was normally.
She never got the similar complaint before
She has not a medication history.
Physical examination

Patient was consious with moderate ill

BP = 120/60 mmHg Pulse = 84x/m, regular, strong

RR = 24x/m, regular Temperature = 36,7oC


General state
Head : Normal Abdomen
Face : Normal I : flat, follow the motion of
Eyes : Normal breath, distended (-)
Nose : Normal A : Peristaltic was normal
Mouth : Normal P : Timpany (+), liver was deaf
Ears : Normal P : Massa (+) at right lumbalis
Neck : Normal region of abdomen and
Chest : Normal Tenderness (+).
Extremity Rectal Toucher :
Superior : Normal
Inferior : Normal
CLINICAL FINDING
LABORATORY FINDINGS
WBC : 21.57+ GDS : 90
RBC : 4.74 Ureum : 23
HGB : 13.8 Creatinin : 0,4
PLT : 279 SGOT : 25
NEUT : 17.82
Diagnose
Abdominal pain e.c

PLANING

USG
CT-SCAN
IVFD
Analgetic
Farmakologi
Antibiotic
H2R agonis

Consult to digestive
Thank You

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