CASE REPORT

I. PATIENT’S IDENTITY
Name : Mr. S
Age : 44 years old
Sex : Male
Religion : Moslem
Job : Employee
Address : Sendang RT/RW 003/008 Tuko Pulokulon Grobogan
No.RM : 01-39-xxxx
Room : Baitus Salam 1
Date of examination : Oct 30th, 2019

II. HISTORY TAKING

Main Problem : Abdominal Pain
History of present illness :
Mr. S came to Emergency Room of Sultan Agung Islamic Hospital Semarang with
complaints of right back abdominal pain since 2 days ago. Pain appeared suddenly and felt
throughout the day without any improvement and interferes with daily activities. In
addition to pain, patients also complain of fever and pain when urinating. The patient has
a history of kidney stones since 1 year ago and has receives treatment, but complaints
reappear. At The Sultan Agung Islamic Hospital the patient was planned for pro
nephrolithotomy by a urologist but the patient’s blood sugar was high so he was consulted
to an internal specialist.

History of previous illness

• Same symptom/illness (+)
• Hypertension history (-)
• DM history (-)
• Alergy history (-)
• Smoking (+)

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 • Alcohol (+)
Family’s history of disease
• Hypertension history (+)
• DM history (+)
Sosio-Economic History
• Economic Impression : enough, BPJS member

III. GENERAL PHYSICAL EXAMINATION

DATE : 30 Oct 2019
 General : feel pain
 Awareness : composmentis
 Vital sign :
BP : 130/70 mmHg
Pulse : 88 x/minute
RR : 20 x/minute
T : 36.5 0C

 BMI (Body Mass Index)

Weight : 77 kg
High : 165 cm
BMI : 28,28 (overweight)

 Head : Mesocephal, alopesia (-)

 Eyes : Anemic conjuntiva(-/-), Icteric sclera(-/-)
 Nose : Symmetric, secret (-), Nostril Breath (-)
 Ears : Normal shape, discharge (-/-)
 Mouth : Cyanosis (-), dry lips (-), snoring (-)
 Neck : Trakhea deviation (-), Lymph Hypertropy (-)
 Extremity : Oedem of lower extremity (-), Oedem of upper extremity (-)
Interpretation : normal

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IV. CHEST EXAMINATION – LUNG

EXAMINATION ANTERIOR POSTERIOR

Inspection - Static RR : 20x/min RR : 20x/min

Thoracal breathing Thoracal breathing
Hyperpigmentasi (-) Hyperpigmentasi (-)
Spider nevi (-) Spider nevi (-)
Atrofi M. Pectoralis (-) Hemithoraks D=S
Hemithoraks D=S ICS Normal
ICS Normal Diameter AP < LL
Diameter AP < LL

Inspection - Up and down of hemitoraks D=S Up and down of hemitoraks D=S

Dinamic Muscle retraction of breathing (-) Muscle retraction of breathing (-)
Retraction ICS (-) Retraction ICS (-)

Palpation Palpation pain (-) Palpation pain (-)

Mass (-) Mass (-)
Sterm fremitus D=S Sterm fremitus D=S

Percution Sonor (+) Sonor (+)

Auscultation Vesicular (+) Vesicular (+)

Whezzing (-) Whezzing (-)
Ronchi basal(-) Ronchi basal(-)
Interpretation : normal

V. THORAX – COR EXAM

INSPECTION Ictus cordis isn’t seen.

JVP normal

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 PALPATION Ictus cordis is palpate at SIC VI linea mid clavicula sinistra
thrill (-)
pulsus epigastrium (-), pulsus para-sternal (-), sternal lift (-).

PERCUSSION  Upper borderline of heart : ICS II left sternal line

 Waist of heart : ICS III left parasternal line
 Lower right borderline of heart : SIC V linea sternalis
dextra
 Lower left borderline of heart : SIC V, 2 cm medial
from linea mid clavicula sinistra

AUSCULTATION - Aortal valve : S1 & S2 standard, additional sound (-)

- Pulmonary valve : S1 & S2 standard, additional sound (-)
- Tricuspid valve: S1 & S2 standard, additional sound (-)
- Mitral valve : S1 & S2 standard, additional sound (-)

Interpretation : normal

VI. ABDOMINAN EXAM

EXAMINATION RESULTS

Inspection Simetrics
Sycatric (-)
Striae (-)
Enlargement of vena (-)
Caput medusa (-)
Spider nevi (-)

Auscultation Peristaltic (+)

Aorta abdominal bruit (-), A. Lienalis, A. femoralis (-)

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 Percussion Shifting dullness(-)
Undulation test (-)
Hepar deaf (-)
Liver span dextra 11 cm
Liver span sinistra 6 cm,
Traube’s space (-)
Costovertebral percussion (+)

Palpation Mass (-)

Pain press (+) upper right abdomen
Hepatomegali (-)
Hepar, kidney & lien are normal
Splenomegali (-)
Murphy’s sign (-)

Interpretation : Abdominal pain

VII. EXTREMITIES
SUPERIOR INFERIOR

Oedem -/- -/-

Cyanotic -/- -/-

Cold Extremity -/- -/-

Capillary Refille <2” <2”

Clubbing Finger -/- -/-

Physiologic Reflex +/+ +/+

Pathologic Reflex -/- -/-

Interpretation : normal

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VIII. SUPORTING EXAMINATION
DATE : 27th October 2019
EXAM RESULT REFERENCE VALUE UNIT
HEMATOLOGY
Haemoglobin 17.6 13.2 – 17.3 g/dl
Hematocrite 50.0 33 – 45 %
Leukocyte 8.81 3.8 – 10.6 Ribu/uL
Trombocyte 262 150 – 440 Ribu/uL
Blood Type / Rh O/Positive -
APTT/PTTK 25.5 21.8 – 28.0 Second
Control 26.2 21.0 – 28.4 Second
PTT 10.0 9.3 – 11.4 Second
Control 11.1 9.3 – 12.5 Second
IMUNOSEROLOGY
HBsAg Qualitative Non-Reactive Non-Reactive -
KIMIA
Random Blood Glucose 417 75 – 110 Mg/dl
Ureum 17 10 – 50 Mg/dl
Blood creatinine 1.01 0.7 – 1.3 Mg/dl
Na, K, Cl
Natrium 140.8 135 – 147 Mmol/L
Kalium 4.47 3.5 – 5 Mmol/L
Chloride 98.0 95 - 105 Mmol/L
Interpretation : Hemoconcentration, Hyperglicemia

DATE : 27th October 2019

EXAM RESULT REFERENCE VALUE UNIT
URINE
Color Yellow -

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 Purification Agak keruh -
Protein Trace <30 (Negative) Mg/dL
Reduction >= 1000 < 15 (Negative) Mg/dL
Bilirubin 1 <1 (Negative) Mg/dL
Reaction / pH =5,0 4.8 – 7.4 -
Urobilinogen 4 <2 Mg/dL
Keton Negative <5 (Negative) Mg/dL
Nitrit Positive Negative -
Mass 1.015 1.015 – 1.025 -
Blood Negative <5 (Negative) Eri/uL
Leukocyte 15 <10 (Negative) Leu/uL
MICROSCOPIC
Epytel sel 2–4 5 – 15 /LPK
Erytrocyte 0–1 0–1 /LPB
Leucocyte 6–8 3–5 /LPB
Cillinder 0 0 – 1 (Hialin) /LPK
Paracyte Negative Negative -
Bacteri Positive 1 Negative -
Fungus Negative Negative -
Crystal Negative -
Mucous Fillament Negative -
Interpretation : Normal

DATE : 28th October 2019

RPG (Contras) 
- Right Hydronephrosis G III E.C. Right Nephrolithiasis Radioopaq (Staghorn Stone) size
5.5 x 3.5 cm.
- Spondylosis Lumbal

DATE : 30th October 2019

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 EXAM RESULT REFERENCE VALUE UNIT
HEMATOLOGY
Haemoglobin 13.9 13.2 – 17.3 g/dl
Hematocrite 37.1 33 – 45 %
Leucocyte 9.76 3.8 – 10.6 Ribu/uL
Trombocyte 205 150 - 440 Ribu/uL
Interpretation : Normal

IX. ABNORMALITY DATA

History Taking
1. Abdominal pain
2. Fever
3. Pain when urinating
4. History of previous illness
5. Family’s history of disease

Physical Examination
1. Overweight
2. Pain (+) upper right abdominal
3. Pain press (+)
4. Costovertebral percussion (+)

Supporting Examination

1. GDS : 417 mg/dl

2. Right Hydronephrosis G III E.C. Right Nephrolithiasis Radioopaq (Staghorn Stone)
size 5.5 x 3.5 cm.
3. Spondylosis Lumbal

X. PROBLEM LIST
1. DM

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 - DM History
- GDS  417
- Family’s history of disease

2. Nephrolithiasis
- Right Hydronephrosis G III E.C. Right Nephrolithiasis Radioopaq (Staghorn
Stone) size 5.5 x 3.5 cm
3. Overweight
- BMI : 28,28

XI. DISCUSSION
1. DM
Assessment
Glycemia Status
Complication :
- Microangiopathy : Diabetic Retinophaty, Nephropathy, Diabetic Neuropathy
- Macroangiopathy : CVD, PAD, CHD
Ip. Dx :
- HbA1c
- Funduscopy
Ip. Tx :
Non pharmacologycal
- Balanced Nutrition therapy
- Low sugar diet
- Exercise : 30 minutes a day
Pharmacologycal
- Humalog 3x1 9UI
Ip. Mx :
- Random Blood Glucose
Ip. Ex :
- Education to patient about DM

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 - Do medical check up regularly
- Diet DM

2. Overweight
Assessment
- BMI : 28,28
Ip. Dx :
- BMI
Ip. Tx :
Non pharmacologycal
- Control daily calories
- Physical exercise
- Change of dietary habit
Ip Mx :
- Monitoring weight
- Waist circumference
Ip. Ex :
 Education to patient about obesity
 Diet high calories

3. Nephrolithiasis
Assessment
- Staghorn stone
Ip. Dx :
- RPG
Ip. Tx :
- Surgery (Consul to Urologist)
Ip Mx :
- Vital sign
- Urine Output
Ip. Ex :

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 Education to patient about nephrolithiasis
 Drink more water
 Do medical check up regularly

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