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Findings Assesment Therapy

• Epigastric pain, vomit, nausea

 GCS: E4V5M6, TD: 130!0, "# $4%, T : 3!,$ oC, ##: &&%

E'e : "a(e Con)ungtiva **, Sc(era icteric **

T+T : orma(

 ec- : .V" 5*& cm, /'mp oes not En(arge

.V" : *

THRORAX

2 : S'mmetrica( cest a(( movement, ictus coris *"a(: S'mmetrica( Voca( remitus, ictus coris : pa(pa7(e

"er: SonorSonor , cariac eng(argement *

8us: 9asic 7reat soun vesica(, ronci **, eeing **; S1 an

S& regu(er, ga((op *, murmur *

ABDOMEN

2ns : (at

8us : 9oe( soun

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Su!ecti"e DataName : Mr. Y, 4 Years O!d

CM : TC : "#nday, $#ne %th &'()

## $ Epi%a&tric 'ain

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Anamne&i&Main &(mptom : E*i+astri Pain

Additional &(mptom :

Patient arrived to U-I hos*ita! to om*!aine*i+astri *ain sine & days a+o. The

om*!ain fe!t ontinio#s!y. The *atient a!so

om*!ain na#sea and vomit times this day.

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Past Media! /istory and Treatment

History of cholelitiasis

0ami!y /istory

denied

"oia! /istorySmoking (-), consuming alcoholic beverages (-)

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)!ecti"e Data

• 1**earane : Moderate I!!ness

• GC" E4M23)

• P : ('5%' mmh+,

• RR: &&65 min#te,

•  T : %.78C

• P#!se : 7465min#te.

• Eye: Pa!e on9#ntiva 5 , s!era iteri

• Ear, Nose, throat : norma!

•  $3P : norma! , )& m, !ym*h nodes no

en!ar+ed

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•  Thora6.

 – I : "ymmetria! hest ;a!! movement, It#s ordis

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#linical *aorator(

• %5'25&'() i!ino+en ',&

e#osit 25 P

ateria! A

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A&&e&&ment

•D'spepsia

•?rinar' Tract 2nection

•+istor' o co(e(itiasis

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Therap(• Ce%on 1%& gr 2V

• Sucra(at 3%1 C

• Vometa 3%1 ta7

• "umpitor 1%1 amp 2V

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'lannin%

+ospita(ie

Cec- (a7 : +&T/, SG@TSG"T, ?rCr,

D"/ A proi( (ipi

2VBD : 22 Butro(it &4 ours

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Than+ ou

Department of Internal

MedicineChristian University of Indonesia