IDENTITY

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

Routine Blood Test

Blood Chemistry
USG Abdominal
Laboratory
Routine blood Blood Chemistry
WBC : x 103/uL GDS : mg/dl
HB : g/dL Ureum: mg/dl
PLT : x 103/uL Creatinine : mg/dl
NEUT : % SGOT : U/L
SGPT : U/L
Protein Total : gr/dL
DIAGNOSIS

Post op. Ascites Drainage

Susp. Abdominal Tumor
MANAGEMENT
Non-Pharmacological Pharmacological
• Bedrest • IVFD
• Oxygen 3 lpm • Antibiotic
• Analgetic
• H2RA
• Consult digestive surgeon
L/O/G/O

Thank You

BAGIAN ILMU
BEDAH