kel 2. 28 mei 2015
TRANSCRIPT
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Findings Assesment Therapy
• Epigastric pain, vomit, nausea
GCS: E4V5M6, TD: 130!0, "# $4%, T : 3!,$ oC, ##: &&%
E'e : "a(e Con)ungtiva **, Sc(era icteric **
T+T : orma(
ec- : .V" 5*& cm, /'mp oes not En(arge
.V" : *
THRORAX
2 : S'mmetrica( cest a(( movement, ictus coris *"a(: S'mmetrica( Voca( remitus, ictus coris : pa(pa7(e
"er: SonorSonor , cariac eng(argement *
8us: 9asic 7reat soun vesica(, ronci **, eeing **; S1 an
S& regu(er, ga((op *, murmur *
ABDOMEN
2ns : (at
8us : 9oe( soun
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Su!ecti"e DataName : Mr. Y, 4 Years O!d
CM : TC : "#nday, $#ne %th &'()
## $ Epi%a&tric 'ain
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Anamne&i&Main &(mptom : E*i+astri Pain
Additional &(mptom :
Patient arrived to U-I hos*ita! to om*!aine*i+astri *ain sine & days a+o. The
om*!ain fe!t ontinio#s!y. The *atient a!so
om*!ain na#sea and vomit times this day.
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Past Media! /istory and Treatment
History of cholelitiasis
0ami!y /istory
denied
"oia! /istorySmoking (-), consuming alcoholic beverages (-)
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)!ecti"e Data
• 1**earane : Moderate I!!ness
• GC" E4M23)
• P : ('5%' mmh+,
• RR: &&65 min#te,
• T : %.78C
• P#!se : 7465min#te.
• Eye: Pa!e on9#ntiva 5 , s!era iteri
• Ear, Nose, throat : norma!
• $3P : norma! , )& m, !ym*h nodes no
en!ar+ed
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• Thora6.
– I : "ymmetria! hest ;a!! movement, It#s ordis
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#linical *aorator(
• %5'25&'() i!ino+en ',&
e#osit 25 P
ateria! A
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A&&e&&ment
•D'spepsia
•?rinar' Tract 2nection
•+istor' o co(e(itiasis
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Therap(• Ce%on 1%& gr 2V
• Sucra(at 3%1 C
• Vometa 3%1 ta7
• "umpitor 1%1 amp 2V
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'lannin%
+ospita(ie
Cec- (a7 : +&T/, SG@TSG"T, ?rCr,
D"/ A proi( (ipi
2VBD : 22 Butro(it &4 ours
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Than+ ou
Department of Internal
MedicineChristian University of Indonesia