IDENTITY

Name : Mrs. K
Age : 45 years old
Sex : Female
Address : Jl. BalaiKota III
Occupation : Housewife
Admission : September 3rd 2019
Doctor in Charge: dr. Ld Rabiul Awal, Sp.B-KBD
 HISTORY TAKING
Chief Complaint:
Pain at right upper quadrant of abdomen
Anamnesis:
Suffered since ± 3 months ago and burdens 3 days before admission. Pain felt
intermittent, the patient initially feels pain in the gut, then moves to the back. Other
Complain, there was headache and nausea, vomitting and fever were denied. Defecate
and urination within normal limit.

There was a history of the same problem in 6 months ago

There were no history of decreased appetite and weight loss
There was no history of other disease
There was no history of previous medication
 PHYSICAL
EXAMINATION
• Generalized state:
Composmentis, moderate illness, well
nourished
• Vital sign:
Blood presure: 140/90 mmHg
Pulse rate: 90 bpm, regular, strong beats
Respiratory rate : 20 breaths/min,
spontaneous, regular, thoracoabdominal
type
Temperature: 36,6’C / axillary
 PHYSICAL
EXAMINATION
Present State:

 Head : within normal limit Chest : within normal limit

 Face : within normal limit Abdomen : localized
 Eyes : within normal limit Upper Limb : within normal limit
 Nose : within normal limit Lower Limb : within normal limit
 Mouth: within normal limit Genitalia : not examinated
 Ears : within normal limit Vertebrae : within normal limit
 Neck : within normal limit
 PHYSICAL
EXAMINATION
Localized State:
Abdomen
• Inspection : Convex, follow the motion of breath,
icterus -
• Auscultation : Peristaltic was normal
• Palpation : Tenderness (+) at hypocondirum
dextra region
• Percussion : Tympani (+)
 PLAN OF DIAGNOSE

Laboratory Test
•Routine Blood Test
•USG Abdomen
LABORATORY FINDINGS
PARAMETER RESULT REFERENCE VALUE

WBC 7.19 x 103/Ul 4,00 – 10,00

RBC 5,01 x 106/uL 4,00 – 6,00
HGB 11.5 g/dL 12,0 – 16,0
HCT 37.0% 37,0 – 48,0
PLT 330x 103/uL 150 – 400
NEUT 5.27 % 52,0 – 75,0
LYMPH 1.28 % 20,0 – 40,0
MONO 0.48 % 2,0 – 8,0
EO 0.15% 1,0 – 0,40
BASO 0,01 % 0,0– 0,10
LABORATORY FINDINGS
REFERENCE
PARAMETER RESULT
VALUE

Ureum 14 18-50 mg/dl

Kreatinin 0,8 0,5-0,9 mg/dl

SGOT/AST 180 <31U/L

SGPT/ALT
243 <31 U/L

GDS 153 70-180

USG ABDOMEN
• Kesan:

Cholelithiasis, ukuran
dan jumlah bertambah
• Tanda-tanda gastritis
 DIAGNOSE

Colic abdomen ec cholelithiasis

DD:
Cholecystitis
 MANAGEMENT
• Non-Pharmacology • Pharmacology
Bed Rest IVFD RL
Education Analgesic injection
Antibiotic injection
H2RA injection

Referred to Digestive Surgeon

Thank You