DUTY REPORT EMERGENCY ROOM 29 TH MAY 2015 ACUTE ABDOMEN WITH OBSTRUCTIVE JAUNDICE CAUSED BY SUSPECTED CHOLEDOCHOLITHIASIS UNCONTROLLED GRADE II ESSENTIAL HYPERTENSION GP on duty: dr. Karen Pandhika & dr. Husnah Co-ass on duty: Raymond Pranata & Grace Fonda Supervisor : dr Soroy Lardo SpPD FINASIM PPDS FKUI Department Of Internal Medicine Indonesia Army Central Hospital Gatot Soebroto
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DUTY REPORTEMERGENCY ROOM29TH MAY 2015ACUTE ABDOMEN WITH OBSTRUCTIVE JAUNDICE CAUSED BY SUSPECTED CHOLEDOCHOLITHIASISUNCONTROLLED GRADE II ESSENTIAL HYPERTENSION
GP on duty: dr. Karen Pandhika & dr. Husnah
Co-ass on duty: Raymond Pranata & Grace Fonda
Supervisor : dr Soroy Lardo SpPD FINASIM
PPDS FKUI
Department Of Internal Medicine
Indonesia Army Central Hospital Gatot Soebroto
RECAPITULATION
1. Mr. Y GERD
2. Mrs. S Abdominal pain in jaundice e.c. cholecystitis
3. Mr. Y dyspnea e.c. suspect COPD
4. Mr. B polycythemia vera
5. Mrs. S dyspepsia + herpes zoster infection
6. Mr. S dyspnea e.c. acute asthma exacerbation
7. Mr. G dyspnea e.c. acute asthma exacerbation +
neurodermatitis + Hepatitis C
8. Mrs. M acute psychosis
9. Ms. G acute gastroenteritis e.c. viral infection
10. Ms. S acute gastroenteritis e.c. suspect food intoxication
PATIENT’S IDENTITY
Name : Mrs. S Age : 61 y.o Occupation : housewife Medical record No : 09-51-xx Address :
ANAMNESIS
Alloanamnesis with patient’s daughter
Chief complaint:
Abdominal pain since 1 week before admission
Additional complaint:
Jaundice
Pale color stool
Dark color urine
1 week before admission
• Sudden onset abd. pain, radiating to epigastrium, back and shoulder
• Dark urine color + acholic stool
• Not relieved with antacid
3 days before admission
• Abd. pain persists
• Sclera looked icteric on both eyes
• 2d before admission whole body jaundice
Days of admission
• Abd. pain persists
• Blood test 1d before admission increase liver function test and bilirubin
HISTORY OF PRESENT ILLNESS
Abdominal pain since 1 week before admission
Site: Right upper quadrant
Onset: sudden at midnight (1 week before admission)
Characteristic: sharp, stabbing
Radiation: to epigastrium, back, and shoulder
Not improve with antacid or food, not relieved by defecation
Continuous throughout the day and interfere with daily
activities
Getting worse with activity and deep inspiration
Weight loss (-)
Associated symptoms:
Jaundice
Sclera 3 days
before admission
Whole body 2 days before admission
Pruritus (-)
Dark urine color (‘tea’ color)
Onset: 1 week
before admission
Frequency: no
changes
No blood, painless
Pale color
stool
Onset: 1 week
before admission
Consistency: no
changes
Blood (-), mucus
(-), steatorrhea (-)
Tenesmus (-), foul
smell (-)
History of other systemic illnesses:
Uncontrolled hypercholesterolemia
Uncontrolled hypertension with BetaBlock™
High uric acid controlled without drug
Habits:
Frequent consumption of fried and oily food
Alcohol bingeing (-)
Smoking (-)
NSAID use (-)
History of past illnesses (including surgery)
Appendectomy at year 2009
Cataract surgeries on both eyes
Patient had once been admitted to hospital because of
abnormally high blood cholesterol and cardiomegaly