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