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TEAM 2sss

Mrs. Suci Mariyati, 41 years old

CM : 00.08.00.64

UGD RS-UKI Cawang, Jakarta

TC

CC: Right hypochondria pain

Date : 04/10/2016

FINDINGS

ASSESSMENT

Right hypochondria pain 12 hours ago


Nausea
Vomit (-)
the colour of urine is dark brown

Physical Examination:
Apperance : sick, GCS : E4
Awareness : Composmentis
BP :
140/90 mmHg
HR :
98 x/min
RR :
24 x/min
T:
37,3 C
Head : Normocephaly
Eye : Pale conjunctiva -/Icteric sclera -/ENT: normal
Mouth : normal

V5

M6

Cholesistitis

THERAPY
IVFD : NS 1 Kolf
Ranitidin 1 amp
Kaptropen supp

: Tuesday, 08:20 PM

PLANNING
- Pro hospitalized

Neck : lymph nodes not enlarge, JVP : 5-2 cmH2O

Thorax :
Ins : movement of chest wall symmetric
Pal : voval fremitus sound symmetric
Per : sonor right=left
Aus : basic sound of breath vesicular,
Ronchi -/- , Wheezing -/Heart sound I & II regular, murmur (-), gallop (-)
Abdominal:
Ins : flat
Aus : bowel sound (+) 4x/min
Per : timpani, percution pain (+)
Pal : supel , tenderness (+)
Extremities :
Edema - - , CRT < 2 , warm acral
- -

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