1. What is the interpretation from all of examination that the doctor give to the patient in this scenario?

yang anamnesis, sama pemeriksaan lab itu kerjaannya dedek sama vika yaa trus yang COR Palpation: Ictus
Cordis palpable in SIC IV normal ato enggak aku masih bingung jg. tp aku tulis normal aja disana.
PHISICAL EXAMINATION: General Appearance: Well, Consciousness: Compos Mentis normal Vital Sign: normal - Pulse: 80 x/minutes normal ( 60-100 x/minutes) - Blood pressure: 120/80 mm/hg normal - Respiratory rate: 20x/minutes normal (16-24 x/minutes) - Temperature: 36,5 C normal Skin: normal Head: mesocephal normal Eyes: - Conjuctiva anemis (-) normal - sclera jaundice (+) Jaundice is a yellow color of the skin, mucus membranes, or eyes. The yellow coloring comes from bilirubin, a byproduct of old red blood cells. Jaundice can be a symptom of other health problems. Everyday, a small number of red blood cells in your body die, and are
replaced by new ones. The liver removes the old blood cells, forming bilirubin. The liver helps break down bilirubin so that it can be removed by the body in the stool.

When too much bilirubin builds up in the body, jaundice may result. Jaundice can occur if: Too many red blood cells are dying or breaking down and going to the liver The liver is overloaded or damaged The bilirubin from the liver is unable to move through the digestive tract properly Jaundice is often a sign of a problem with the liver, gallbladder, or pancreas. Infections, use of certain drugs, cancer, blood disorders, gallstones, birth defects and a number of other medical conditions can lead to jaundice. Ears: Secret (-) normal Nose: Secret (-) normal Mouth: tongue with no dirty and teeth with no caries normal Pulmo: normal

Insection: retraction (-), delay of breathing motion (-) normal Palpation: delay of breathing motion (-) normal Percussion: Sonor in the both of lung normal Auskultation: vesikuler, ronkhi (-), Wheezing (-/-) normal

Cor: normal Insection: Ictus Cordis invisible normal

Palpation: Ictus Cordis palpable in SIC IV normal (?)

Percussion: Redup normal Auskultation: Regular, Dull (-) normal

Abdomen: Insection: abdomen equal to the chest normal Palpation: Hepar and Lien invisible normal (the patient maybe didnt got a hepatomegaly or a splenomegaly), Tenderness in the right upper quadrant of abdomen (+) The following medical conditions are some of the possible causes of Right-upperquadrant tenderness, like Hepatic trauma, Kidney subcapsular rupture, Liver rupture, Liver traumatic cyst, Hepatitis, Hepatic abscess, Pancreatitis, Primary sclerosing cholangitis, Hepatic necrosis, Kidney stone/urolithiasis/nephrolithias, Gastric ulcer, Biliary colic, Choledocholithiasis, Cholelithiasis, Fatty liver, Pneumonia, Hydatid cyst, Cholangiocarcinoma, Pregnancy, Cholestasis, OCPs, Subphrenic abscess, Fitz-Hugh-Curtis syndrome, Right sided cardiac failure, etc. There are likely to be other possible causes, so as a doctor we must know more about the patient symptoms. Percussion: shifting dullness (-) normal (the patient maybe didnt got an ascites) Auskultation: peristaltic : well, Murphys sign: (-) normal (the patient maybe didnt got a cholecystitis)

Ekstremitas: Acral: warm, Pulse: firm normal

Daftar Pustaka:
http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001259/ http://www.rightdiagnosis.com/sym/right_upper_quadrant_tenderness.htm