IDENTITY

Name
: mrs. S
Age
: 52 years old
Address : Bende
Admission : April 18th, 2016
DPJP : dr. Faruly Wijaya S
Limba, Sp. B

HISTORY TAKING
(HETEROANAMNESIS)
Chief
Complain : swelling in the right armpit

Anamnesis: suffered since 1 weeks ago

before admitted to the hospital . Initially
raised bumps like seed
then
increasingly bloated. Two days ago
bumps burst and ooze pus. History of
fever since 1 week ago (+), history of
DM (+), histroy of drug consumed
glibenclamide.

General Situation

PHYSICAL EXAMINATION

Next...

CLINICAL FINDING

LABORATORIUM FINDING

COUNTING BLOOD CELLS

WBC 21.39 [10^3/uL]
HGB 12.5 [g/dL]
HCT 37.0 [%]
PLT 310 [10^3/uL]

BLOOD CHEMISTRY
GDS : 294

Clinic
al
Diag
nose

ABSCESS IN THE RIGHT ARMPIT

PLANNING EXAMINATION : Counting blood cell

Blood chemistry : GDS

PLAN THERAPY

Intravenous Fluids
Intravenous Antibiotics
Intravenous Analgetic
Consult to the general surgeon

L/O/G/O

Thank
You
BAGIAN ILMU BEDAH