Name: Mr.

H
Age: 30 years
Male gender
Address: Jalan Anggrek
Occupation: Farmer
Javanese ethnic
Islam
Status: Married
No. RM: 23.55.67
MRS: 3/09/2016

I.

SUBJECTIVE
a. Main complaint
Upper right abdominal pain
b. Disease History Now
Patients present with right upper abdominal pain since two years before came to
hospital. Pain is felt suddenly and settled and intermittent to severe intensity for
1-3 hours and then disappear slowly. Furthermore, the pain came back. Pain is felt
on the upper right abdomen until the pit of the stomach and spread to the back
right waist, and strongly felt when activity. If the patient appears pain until a cold
sweat with the pain and can not perform any activity. Patients often taking ulcer
medication if you develop stomach pain and heartburn. Breathlessness and chest
pain denied.
Patients also complain of nausea (+) but not accompanied by vomiting. Every
meal was admitted patients often feel nauseous. Patients also said often complain
of chills but not accompanied by fever. Patients also complain of bloating. Patients
say that the defecation and urination no complaints, pain during defecation (-),
blood / black (-), pain when urinating (-), urinated sandy (-), flatus (+).
c. Past medical history
Patients had never experienced similar complaints before. However, patients
admitted to a history of stomach ulcers for a long time but rarely relapse. If the
pain is usually only in the solar plexus and cured only if taken antacid.
History of hypertension (-), DM (-), heart disease (-) and malignancies (-). A
history of jaundice (-).
d. Family Disease History
Nothing in the families of patients who experienced a similar complaint with the
patient. History of hypertension (-), DM (-), heart disease (-), a history of asthma
(-). A history of malignancy (-). A history of gallstones (-).

e. Treatment history
Patients only the consumption of antacids to resolve the complaint. History taking
pain relieving drugs or arthritis drug denied.
f. Allergy History:
Patients have never had a history of allergies to medications and certain foods.
g. Personal and Social History
Patients work as farmers. Patients admitted to never drink alcohol. Patients had
never smoked

II. OBJECTIVE
a. Present Status
General Situation: Medium
Pain impression: Medium
Awareness: Compos mentis / E4V5M6
b. vital Sign
Blood presure: 100/60 mmHg
Nadi: 92 x / min, heave, regular
Respiratory: 18 x / minute
Temperature: 37.1 C
c. Status Generalis
Head
Shape: normocephali
Hair: black hair, is not easily removed, equal distribution
Eye: palpebrae edema - / -, pupil isokor, CA - / Ears: normal, tympanic membrane intact, wax - / Nose: normal shape, secretions -, nostril breath - / Mouth: faring no hyperemia, T1-T1
Neck: KGB is not enlarged, the thyroid gland is not enlarged
thorax
Inspection: symmetrical chest wall movement
Palpation: motion symmetrical breath, vocal fremitus symmetric
Percussion: sonor in both lung fields
Auscultation: Pulmo SN vesicular, crackles (- / -), wheezing (- / -)
Cor: I & II heart sound normal, murmur (-), gallops (-)
Abdomen
inspection: Symmetrical abdominal wall, the mass (-), distention (-), venous collaterals (-),
caput medusae (-)
Auscultation: Noisy intestine (+) normal, metallic sound (-), noisy aorta (-)

palpation:
Turgor:Normal
Tonus:Normal
Tenderness (+) in epigatrik and hipokondrium dextra, Murphy sign (+), abdominal distension
(-), defense muscular (-), tenderness mac Burney (-), Rovsing sign (-), psoas sign (-),
obturator sign (-), liver / Lien / Ren: impalpable
Percussion:Timpani throughout the grounds abdomen CVA tenderness (-)
Extremity
Upper limb: there is no edema, akral warm, not pale, no cyanosis.
Lower extremity: akral warm, not pale, no cyanosis.
d. Laboratorium Test
Parameter
HGB
RBC
WBC
HCT
PLT
Bilirubin Total
Bilirubin Direk
Biliribin Indirek
CT
BT
Albumin
Ureum
Kreatinin
Uric acid
Cholesterol total
Trigliserida
Cholesterol HDL
Cholesterol LDL
SGOT
SGPT

USG Abdomen

Hasil
19,5
6,3
10,3
48
246.000
1,14
0,31
0,83
600
330
4,43
30
0,98
7,5
149
102
46
83
23
34

Normal
L : 13,0-18,0 g/dL
L : 4,5 5,8 [106/L]
4,0 11,0 [103/ L]
L : 40-50 [%]
150.000-400.000
<1,00 mg/dL
<0,25 mg/dL
<0,25 mg/dL
5-10 minute
<5minute
3,5-5,5 g/dL
21-53 mg/dL
0,17-1,5
L: 4,0-7,0 mg/dL
<200 mg/dL
<165 mg/dL
>40 mg/dL
<180 mg/dL
L: <37 U/L
L: <42 U/L

Hepatic: normal size, sharp angles, regular surface, ekhogenitas normal parenchyma
homogeneous, nodules (-), bile duct intrahepatal and ektrahepatal not widen, v. Porta, v.
Hepatic not widen
Gall bladder: normal size, regular wall, were two stones the size of 3-5 mm size
Pancreas: Normal size, parenchyma homogeneous, duct pakreatikus not widen
Spleen: Size enlarged, ekhogenitas parenchyma homogeneous, v. Splenic not widen
Right-left kidney: normal size
Bladder: Unoccupied, the walls are not thickened, not visible stone
impression:
multiple cholethiasis
splenomegaly
R/o Thorax

Impression: Cardiac and lungs normal

Therapy
Fasting
Pro Laparoscopy
IVFD RL: D5% (1: 1) 16 drops per minute
Ceftriaxone injection 2x1 g (ST)
Ketorolac injection of 3x30 mg (if necessary)
Ranitidine injection 3x1 g
preparation Operations
consul Anesthesia