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