Morning Report 17 November 2015

EDINA MAFISAH

Patient identity (1)

▪ Name : Mr. MJ

▪ Sex : Male

▪ Age : 40 years old

▪ Address : Mekar Sari

Chief complaint

▪ Pain in the right abdomen

Present illness history

Patient came to the ER with complain of pain in the right abdomen since 8 hours ago. Pain appear intermittently, felt like it was squeeze, and pass through the back. Pain radiated to the groin. Complain of fever (-), nausea (+), vomiting (+) more than 10 times, lose appetite (+), normal defecation.

▪ Since a week ago patient felt the amount of urine volume that came out was decrease but the frequency of urinate was increased. One day ago patient had reddish colored urine. History of intermittently pass gravel, sand, or blood, and pain during urinate was denied. Patient said he consume enough water and never have these symptoms before.

Past medical history

▪History of hypertension (-)▪History of DM (-)▪History of trauma (-)

Physical examination

Vital sign▪ GCS : 15 (Compos Mentis)▪ Blood pressure : 120/80▪ Hate rate : 96 x / min ▪ Respiratory rate : 20 x / min▪ Temperature : 36,3°C

Physical examination

▪ Head: normosefali▪ Eyes: anemic conjunctiva (-/-), icteric sclera

(-/-), ▪ Pulmonary: Normochest, breath sounds

basic: Vesicular (+/+), Wh (- / -), Rh (- / -)▪ Heart: Regular S1S2, Galoop (-), Murmur (-)▪ Abdomen: flat, bowel sounds (+) normal,

tympani, tenderness in right lumbar, right iliac, and hypogastric region

▪ Extremities: CRT <2”

Physical examination

▪ Urology status▪ a/r flank dextra et sinistra:

▪ Ballotement (-/-)▪ CVA knocking pain (+/-)▪ Tenderness (-/-)

▪ a/r SP:▪ Blaas felt empty▪ Tenderness (+)

Laboratory test

▪ Hb : 17,2 gr/%▪ WBC : 12.600 /mm3▪ RBC : 5,40 /million▪ Trombocyte : 238.000 /mm3▪ Ht : 46 vol%▪ Uric acid : 5,23 mg/dl▪ Creatinin : 1,27 mg/dl▪ Ureum : 38 mg/dl

Pemeriksaan Laboratorium▪ Urin:

▪ Protein : +▪ Bilirubin : -▪ Urobilin : +▪ Warna : light brown▪ PH : 6,0▪ Sedimen :

▪ Leukosit : 10-11▪ Eritrosit : full▪ Epitel : +▪ Kristal : Calcium oxalate

Diagnosis

▪ Colic abdomen ec susp. nephrolithiasis

Suggested examination

▪ USG▪ BNO

Therapy IVFD RL 20 dpmCefotaxime 3 x 1 grRanitidin 2 x 1 ampKetorolac 3 x 1 amp

Prognosis

▪ Ad vitam : bonam▪ Ad functionam : bonam▪ Ad sanactionam : dubia ad bonam