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    BST Kolelitiasis

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    fuji
    This document provides information about a 65-year-old female patient who presented with epigastric pain. Her chief complaint was epigastric pain for the past month, occasionally radiating to her back, and worse after eating fatty foods. On examination, she had mild tenderness in her epigastric region. The differential diagnoses included cholelithiasis, cholecystitis, and dyspepsia syndrome. Laboratory tests and ultrasound of the abdomen were proposed to determine the diagnosis. A diagnosis of epigastric pain due to cholelithiasis was made. The treatment plan included diet education, rest, analgesics, antibiotics, and potential cholecystectomy surgery.

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    BST Kolelitiasis

    Uploaded by

    fuji
    171 views17 pages
    This document provides information about a 65-year-old female patient who presented with epigastric pain. Her chief complaint was epigastric pain for the past month, occasionally radiating to her back, and worse after eating fatty foods. On examination, she had mild tenderness in her epigastric region. The differential diagnoses included cholelithiasis, cholecystitis, and dyspepsia syndrome. Laboratory tests and ultrasound of the abdomen were proposed to determine the diagnosis. A diagnosis of epigastric pain due to cholelithiasis was made. The treatment plan included diet education, rest, analgesics, antibiotics, and potential cholecystectomy surgery.

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    This document provides information about a 65-year-old female patient who presented with epigastric pain. Her chief complaint was epigastric pain for the past month, occasionally radiating to her back, and worse after eating fatty foods. On examination, she had mild tenderness in her epigastric region. The differential diagnoses included cholelithiasis, cholecystitis, and dyspepsia syndrome. Laboratory tests and ultrasound of the abdomen were proposed to determine the diagnosis. A diagnosis of epigastric pain due to cholelithiasis was made. The treatment plan included diet education, rest, analgesics, antibiotics, and potential cholecystectomy surgery.

    Copyright:

    © All Rights Reserved
    Download as PPT, PDF, TXT or read online from Scribd
    Download as ppt, pdf, or txt
    171 views17 pages

    BST Kolelitiasis

    Uploaded by

    fuji
    This document provides information about a 65-year-old female patient who presented with epigastric pain. Her chief complaint was epigastric pain for the past month, occasionally radiating to her back, and worse after eating fatty foods. On examination, she had mild tenderness in her epigastric region. The differential diagnoses included cholelithiasis, cholecystitis, and dyspepsia syndrome. Laboratory tests and ultrasound of the abdomen were proposed to determine the diagnosis. A diagnosis of epigastric pain due to cholelithiasis was made. The treatment plan included diet education, rest, analgesics, antibiotics, and potential cholecystectomy surgery.

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    © All Rights Reserved
    Download as PPT, PDF, TXT or read online from Scribd
    Download as ppt, pdf, or txt
    of 17

    Bed Site Teaching

    (BST)
    Ica Syafitri K - 121004056
    Preceptor :
    dr. Liza Nursanty, SpB, M.Kes, FINACS

    SMF Bedah
    RS Al-Islam Bandung
    Program P3D - Fakultas Kedokteran
    Universitas Islam Bandung
    Tahun 2015

    Patient Identity

    Name
    Age
    Sex
    Address
    Religion
    Ras
    Occupation
    Marital status
    date of examination

    : Mrs. S
    : 65 years old
    : Female
    : Cileunyi
    : Islam
    : Sundanese
    : house wife
    : married
    : 9/6/2015

    Chief Complaint

    Epigatric pain

    Patients come to the Surgical Clinic of AlIslam Hospital with complain of epigatric pain since
    1 month before going the hospital. Its 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 its 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
    Consciousness

    : Moderate sick
    : Compos mentis

    Vital Signs:
    Blood pressure
    pulse
    respiration
    temperature

    : 130/80 mmHg
    : 80 x / min
    : 20 x / min
    : 36,5oC

    Head
    anemic conjunctiva (-), sclera icteris (-), pupil round isokor, light reflex
    direct and indirect + / +
    Neck
    JPV not increased
    An enlarged thyroid gland (-)
    KGB no enlargement (preauricular, retroauricular, submandibular,
    submental, cervical anterior and posterior)
    Thorax
    Symmetrical shape and motion
    Cor
    S1 and S2 heart sounds normal regular, murmur (-)

    Pulmo
    VF (+), right = left
    Sonor (+), right = left
    Ronchi and wheezing (-)
    Abdomen
    See status localist
    Ekstremity
    feel warm
    Edema - / CRT <2 seconds

    Status Localist
    Abdominal Region
    Inspection
    PalpasI
    Percussion
    Auscultation

    : flat
    : soft, tenderness (+) in the epigastric
    region, Murphy's sign (-).
    : Pekak samping (+), pekak pindah (+)
    : bowel sounds (+) normal

    DIFFERENTIAL DIAGNOSIS
    -Kolic abdomen e.c DD :
    1. kolelithiasis
    2. kolestisitis
    3. 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 rest
    Fasting until the pain is reduced / lost

    SPECIAL
    Giving hydration
    analgesic
    antibiotics
    Surgery
    cholecystectomy

    PROGNOSIS
    Quo ad vitam
    Quo ad functionam
    Quo ad sanasionam

    : dubia ad bonam
    : dubia ad bonam
    : dubia ad bonam

    TERIMA KASIH

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