Morning Report

July 28 July 2018 DM Elvi

Surgery Dept. Counsultant DM Candida
dr. Alders A. K. Nitbani, Sp.B
PATIENT’S ID
Name : Mr. KM
Age : 23 years old
Gender : Male
HISTORY TAKING
Data was collected in emergency room on July 28th 2018, from autoanamnesis at
03.00 am
Chief complain : abdominal pain
Current History :
patient came to hospital with the chief complain pain in the upper left abdomen since
20.00 (27/08/2018). The pain wasn’t continuously appear and get worse. when it
arises, the pain can persist about 10-15 minutes. The pain initially arises on the left
back, then spreads to the upper left abdomen and sometimes to the left thigh. Patients
also complain of pain during urination, the pain arises shortly after the patient wants
to urinate. Pain felt at the tip of the penis. The patient also said that he often felt
dissatisfied after urination. Urine volume slightly, dripping and red color like tea.
This complaint was first experienced by the patient.
There was no history of trauma, vomit, fever and nausea
 Physical Examination
VITAL SIGN
 Awareness : Compos Mentis
GCS = 15 (E4V5M6)
 Blood Pressure : 130/80mmHg
 Temp : 36,5 degree Celcius (axillar)
 Pulse Rate : 96 x/min, regular
 RR : 22 x/min
 VAS : 6-7 (abdominal pain)
 GENERAL STATUS
 Skin : brownish, normal skin turgor, no jaundice, no cyanosis, pallor
(-)
 Eyes :
 Conjunctiva : Pallor -/-
 Sclera : Icteric -/-
 Pupil : round, isocor +/+, direct light reflexes +/+
 Nose : epistaxis (-)
 Mouth : moist lip mucosal
 Ears : no discharge
 Neck : no palpable lymph node, normal neck movement
• PULMO
• Inspection : symmetrical chest movement
• Palpation : no pain, no mass palpable
• Percussion : sonor on both hemithorax
• Auscultation : vesicular breath sounds (+ /+), rhonchi (-/-),
wheeze (-/-)

• COR
Inspection : no seen Ictus Cordis
Palpation : no palpable Ictus Cordis
Percussion : normal heart border
Auscultation : single S1 – S2, regular, Murmur (-), gallop (-)
ABDOMEN
• Inspection : flat, lesion (-), mass (-)
• Auscultation : normal bowel sound
• Palpation :
pain (+) , ballotement test -/- ; CVA -/+
- + +
- - +
- - -
• Percussion : tympani in all abdominal regions

EXTREMITY :
• warm, cyanosis (-), CRT < 2 seconds
 Lab results on ER

Hb 13,6 12 - 16

Hematocrite 4,61 37 - 47

MCV 87,9 81 - 96

MCH 29,5 27 - 36
Leukosit 11,51 x 103 4 - 10
86,2 %
Neutrofil
Trombosit 261 x 103 150 - 400
 Urinalysis

Warna Kuning keruh

Blood +3
Protein (+3) +3
Epitel 5-8/LP
 ASSESMENT
Urolithiasis
PLANNING DIAGNOSIS
- Abdominal X-ray
-BNO-IVP
 PLANNING
Non-Pharmacologic Treatment plan :
Adequate fluid intake
Pharmacologic Treatment plan
Antrain 1 amp
If diameters < 5mm  Inj furosemid
Endourology (litotripsi)