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MORNING REPORT
27TH Oct 2015
PATIENT IDENTITY
• Name : Tn. M.A• Gender : male• Age : 60 th• Occupation : farmer• Address : lamongan • Ethnic : javanesse• Religion : moeslem
SUMMARY OF DATABASE
• Chief of complaint:– Severe pain in the side right and back, below the
ribs
SUMMARY OF DATABASE• History of present illness:
– Severe pain in the right side and back, below the ribs since 2 days ago.– Pain that spreads to the lower abdomen and groin– Pain that comes continuesly– Pain on urination denied– Pink, red or brown urine denied– Cloudy or foul-smelling urine denied– Nausea and vomiting denied– Persistent need to urinate– Urinating more often than usual, but in a small amounts of urine (not
complete)– Fever and chills denied– Bowel symptoms denied
• History of past illness:– Same complaint before denied– HT and DM denied– History of surgery denied
• History of family illness:– same complaint before/ kidney stone denied– DM and HT denied
• History of social iless:– Not drinking enough water each day
PHYSICAL EXAMINATION
• Vital Sign:– Blood Pressure : 122/74 mmHg– Pulse Rate : 81 x/minutes– Respiration Rate : 20x/minutes– Temperature : 36.5 ⁰C
Generalis Examination:
• Head/Neck: anemis -/-, jaundice -/-, cyanosis -/-, dyspnoe -/-
• Chest (Pulmo):• Inspection: symmetrical, retraction -/-• Palpation: normal/ normal• Percussion: sonor/sonor• Auscultation: vesicular/vesicular, Rh -/-, Wh -/-
• Cor:• Inspection: Vussorue cardiac, Ictus cordis(-)• Palpation: ictus (-), thrill (-)• Percussion: in normal limit• Auscultation: S1/S2 single murmur -, gallop –
• Abdomen:• Inspection: Flat, soepel, mass (-)• Palpation: soepl, hepar and lien not palpable, NKCVA (+/-)• Percussion: tymphani• Auscultation: bowel sound (+) Normal
• Extrimity : • warm, dry, red, swollen (-), CRT < 2sec
LABORATORIUM
• Hb : 11.4• RBG : 97• Lekosit : 10.6• Serum creatinin : 1.2• Platelets : 247• Ureum : 38
IMAGING (BOF)
CLUE AND CUE
• Men, 60th
• Severe pain on the flank dextra• Retensio urine• NKCVA +/-• BOF photo: 2 stones radioopaque with size
2x2.5 cm located as high as L3-L4
PROBLEM LIST
• Nephrolithiasis dextra
ASSESSMENT
• Nephrolithiasis dextra
PLANNING DIAGNOSIS
• Urinalysis• USG abdomen
TREATMENT
• Ivfd Asering 1500cc/24 jam• Inj. Ketorolac 2x1• Levofloxacin 1x500 mg• Pro consult Sp.U
EDUCATION