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Name : Mrs. N
Age : 57 years old
Sex : Female
Adress : Asera
Admission : December, 31th 2017
Doctor in Charge : dr. Tedjo Arianto, Sp.B, KBD.
HISTORY TAKING
• Main Complaint : Abdominal pain
• Anamnesis :
The patient came to the hospital with complaint abdominal pain that
getting worse since 3 days ago. The pain in the whole abdomen and felt
continously. Another complaint are crowded (+), nausea (+), vomitting (+)
and no appetite (+). Defecated and urination within normal limit.
History :
There was history same complaint (+)
There was history of fever (+)
There was history of digestive surgical (+) ascites drainage about 11
days ago
There was history of medication (+)
GENERAL STATE
General Condition :
Severe illness, Composmentis, Poor nutritional status
Vital Sign :
BP : 80/50 mmHg
RR : 30x/min
HR : 92x/min regular, weak
T : 37,00c
• Head : Within normal limit
• Face : Within normal limit
• Eye : Conjunctival anemis +/+
• Nose : Within normal limit
• Mouth : Within normal limit
• Ear : Within normal limit
• Neck : Within normal limit
• Chest : Within normal limit
• Stomach : Localized status
• Upper and lower limb : Within normal limit
LOCALIZE STATE
Abdomen region
Inspection : Flat, following motion of breath (+),
Distended (-) Seemed drain (+), Seeped in
bandages (+), smelled (+)
Auscultation : Peristaltic (+) within normal limit
Palpation : Tenderness (+), Mass (+) at umbilical
region
Percussion : Tympani (+)
Clinical Findings
PLANNING
Thank You
BAGIAN ILMU
BEDAH