Bed Site Teaching (BST)

Ica Syafitri K - 121004056

Preceptor :dr. Liza Nursanty, SpB, M.Kes,

FINACS

SMF BedahRS Al-Islam Bandung

Program P3D - Fakultas Kedokteran Universitas Islam Bandung

Tahun 2015

Patient Identity

• Name : Mrs. S

• Age : 65 years old

• Sex : Female

• Address : Cileunyi

• Religion : Islam

• Ras : Sundanese

• Occupation : house wife

• Marital status : married

• date of examination : 9/6/2015

Chief Complaint

Epigatric pain

Patients come to the Surgical Clinic of Al-Islam Hospital with complain of epigatric pain since 1 month before going the hospital. It’s felt by patients were intermittently. Pain is stabile, and not increased. She feel pain suddenly and it can be disappear within a few minutes. Sometimes, pain perceived are spreading to the back right. Pain felt by the patient especially after eating fatty foods.

The complaints of pain in the epigastric first time felt since 5 months ago, but it’s felt intermittently. The complaints is accompanied with nausea and vomiting 3 times SMRs and there is abdominal bloating. Patients also complain of fever was not very high (the patient does not measure the temperature).

Patients was deny if there are high fever and severe abdominal pain at all part of stomach. Patient was deny if there is a change urination and defecation and patient was deny if the skin and eyes look yellowish. Patients was deny if there are burning sensatin in epifastric and feeling full quickly.

In the beginning the pain disappears with taking medication, but the longer the pain continues to happen even after taking medication. Patients prefer of eating fried foods and high-fat foods. No families of patients who has the same complaint with her. Patients has a history of renal disease for about 2 years.

Physical Examination

General state and Vital Signs:

General State : Moderate sickConsciousness : Compos mentis

Vital Signs:Blood pressure : 130/80 mmHgpulse : 80 x / minrespiration : 20 x / mintemperature : 36,5oC

Head

anemic conjunctiva (-), sclera icteris (-), pupil round isokor, light reflex direct and indirect + / +

Neck

JPV not increasedAn enlarged thyroid gland (-)KGB no enlargement (preauricular, retroauricular, submandibular, submental, cervical anterior and posterior)

Thorax

Symmetrical shape and motion

CorS1 and S2 heart sounds normal regular, murmur (-)

Pulmo VF (+), right = leftSonor (+), right = leftRonchi and wheezing (-)

AbdomenSee status localist

Ekstremityfeel warmEdema - / -CRT <2 seconds

Status Localist

Abdominal Region

Inspection : flatPalpasI : soft, tenderness (+) in the epigastric

region, Murphy's sign (-).Percussion : Pekak samping (+), pekak pindah (+)Auscultation : bowel sounds (+) normal

DIFFERENTIAL DIAGNOSIS

-Kolic abdomen e.c DD :1. kolelithiasis2. kolestisitis3. Syndrome dyspepsi

PROPOSED EXAMINATION

Lab:-Routine blood test-Profile lipid-Bilirubin test-liver function test

USG abdomen

DIAGNOSIS

Colic abdomen e.c kolelithiasis

TREATMENT

GENERAL

Education illness (avoid foods with a high fat content, such as offal, oily foods, and nuts)bed restFasting until the pain is reduced / lost

SPECIAL

Giving hydration

analgesic

antibiotics

Surgery

cholecystectomy

PROGNOSIS

Quo ad vitam : dubia ad bonamQuo ad functionam : dubia ad bonamQuo ad sanasionam : dubia ad bonam  

TERIMA KASIH