laporan pagi abdominal pain
DESCRIPTION
contohTRANSCRIPT
7. Mrs. Risma/30 yo/August 25th 2013 at 22.30
• Chief Complain : Right lower abdominal pain• History :
Since 1 day before admission, patient complained about stomach pain in the right quadrant which appeared suddenly and intermitten. The chief complain wasn’t accompany with fever, nausea, vomitting, and decreasing of eat appetite. Patient had a same complain history since 1 month ago and hospitalized at Ansari Saleh Hospital for 5 days. The chief complain reappeared 2 days ago and patient gone to Poli Ginecology and Poli Surgery at Ulin General Hospital, the result wasn’t abnormality. Patient had known for having cyst history and she’s mestruating now.
General status
AlertVital sign :– BP : 110/80 mmHg - T : 36,6 0 C– RR : 20 x/minute - HR : 78
x/minute
•Eye : anemic conjunctivae (-/-), icteric sclerae (-/-)•Mouth : wet mucous, •Neck : increase of JVP (-), enlargement of limph node (-)
Head/Neck
•I : symmetric respiratory movement, retraction (-), laceration (-)
•P : symmetric VF•P : Sonor in all lung field•A : symmetric VBS, Rh (-/-), Wh (-/-)
Chest
•Anemic (-) edema (-), parese (-)
Extremities
Secondary SurveyAbdomen :• I : Flat and soft• A : normal bowel sound• P : H/L/M not palpable, tenderness
(+) in RUQ, epigastrium, RMQ, RLQ.• P : tympanic in all quadrants
Rectal Tousse :• Tonus sphincter ani strong, clear mucose, skibala palpable, ampula recti isn’y colaps
Handscun : Faeses (+), blood (-)
Clinical Picture
Laboratory (RS Ulin 26th Agt 2013, 02:55)
Pemeriksaan Nilai RujukanHemoglobin 13,1 12,00-16,00 g/dlLeukosit 17,6 4,0-10,5 ribu/ulEritrosit 4,46 3,90-5,50 juta/ulHematokrit 38,6 37,00-47,00 Vol%Trombosit 442 150-450 Ribu/ul
RDW-CV 14,3 11,5-14,7 %
MCV 86,7 80,0-97,0 fl
MCH 29,3 27,0-32,0 pg
MCHC 33,9 32,0- 38,0 %
Gran % 72,3 50,0-70,0 %
Linfosit % 19,8 25,0-40,0 %
MID % 7,9 4,0-11,0 %
GDS 144 < 200 mg/dl
Laboratory (RS Ulin 26th Agt 2013, 02:55)
Pemeriksaan Nilai Rujukan
PT 9,9 9,9-13,5 detik
INR 0,88
APTT 25,3 22,2-37,0 detik
SGOT 28 0-46 U/I
SGPT 30 0-45 U/I
Ureum 17 10-50 mg/dl
Creatinin 0,5 0,7-1,4 mg/dl
Natrium 139,5 135-146 mmol/l
Kalium 3,6 3,4-5,4 mmol/l
Chlorida 110,4 95-100 mmol/l
Laboratory (RS Ulin 26th Agt 2013, 02:55)
Pemeriksaan Nilai RujukanURINALISAWarna – Kekeruhan Kuning - keruh Kuning-jernihBJ 1.030 1.005-1.030pH 6,0 5.0 -6.5Keton Negative NegativeProtein – Albumin Trace Negative
Glukosa Negative Negative
Bilirubin Negative NegativeDarah Samar + 3 NegativeNitrit Negative NegativeUrobilinogen 0,2 0,1-1,0Leukosit Negative Negative
Laboratory (RS Ulin 26th Agt 2013, 02:55)
Pemeriksaan Nilai RujukanURINALISA (Sedimen)Leukosit 1-23 0 – 3Eriythrosit Many 0 – 2 Selinder Negative NegativeEpithel 1 + 1 +Bakteri 1 + Negative
Kristal Negative Negative
Lain-lain Negative Negative
Rontgen (RS Ulin 26th Agt 2013)
Thorax AP
USG Appendix, adnexa, and uterus (RS Ulin 25th Agt 2013)
Impression:- Periappendicular mass ec. Inflamation-- Renal bilateral, VU, and uterus doesn’t have any abnormality.-- Ascites (-)
Working Diagnosis
• Obs. Stomach pain ec. periappendicular mass ec. inflamation
Management• Obs. TNRS• IVFD RL 20 gtt per minute• Fasting (+)• Pro exploration laparatomy cito