Morning Report

July, 17th 2013

Patient’s identity
 Name

:Siti Muhaiyah  Sex :Female  Age :54 years old  Religion : Islam  Ethnic : Banjar  Address : makmur mulia village, satui  Occupation : housewife  Hospitalized since :july, 16th,2013

ANAMNESA
 Main Complain: flank pain  History of Present Illness:

The flank pain occured since 2 weeks ago. It appears suddenly , intermittent and there wasn’t spread of pain anywhere. The patient had intermittent fever one week ago. The patient felt nausea and watery vomitted 5 times a day. The patient had decrease appetite. The frequency of urination was normal and there’s no pain during the process. The volume of urine was decrease.The patient feels there’s some sand in her urine. The stool was normal. When she was young, the patient got a ureter stone operation.
 Other illness: HT (-), Urinary tract infecton (-)

Ureterolitiasis (+)  History of family illness: HT (-).

Physical Examination
GCS : 4-5-6 Weight : 45 kg Height : 150 BMI : 20,0 kg/m2

Vital Sign  Blood presure : 140/80 mmHg, measured at right arm, when patient lying down, using aneroid sphygnomanometer.  Pulse : 80x/minutes, reguler and strong  Respiratory rate : 20x/minutes, thoraxoabdominal  Temperature : 36,2oC, measured using

Physical Examination
 Head and Neck    

of Eyes sclera (-/-) Thorax Cor Abdomen shifting (+/+).

: Bruit (-), Increasing of JVP (-), enlargement Lymph (-) : Anemic konjunctiva (+/+), icteric : Rh (-), Wh (-). : S1-S2: single, murmur (-) : Flat. Hepar, lien, and mass unpalpated. No dullness. Costovertebrae angle pain -Abdominal pain.
+ + +

 Extremitas

: oedema (-) paralyze (-)

Laboratory Finding
 Hb

 Leu
 Eryt  Ht

 MCV
 MCH  MCHC

 Ureum
 Crea

9,3 g/dl 11,9 ribu/ul 2,91 juta/ul 27,2 vol% 93,8 31,9 34,1 126 7

PROBLEM LIST
1. Susp Urolithiasis
2. 1st Grade Hypertension 3.Anemia Normochromic Normocitic 4. Acute Renal Failure

Cue and Clue Anamnesa Flank pain Sand in urine History of Nephrolithiasis operation Physical Examination Costovertebrae angle pain (+/+)

Probl List Susp. Urolithiasi s

Idx Nephrolithiasi s Ureterolithiasi s Vesicolithiasis

PDx Urinalysis USG Abdomen BNO-IVP

PTx Inj Ceftriaxone 2 x 1 Inj. Ketorolac 3 x 1 Co. Urology Department

Pmo Vital sign

Cue and Clue
Anamnesis: Physical Examination : BP : 140/80

Probl List

Idx

PDx

PTx

Pmo

HT grade 1

HT grade 1

Profil lipid E.C.G

Furosemide 1 x 1

-Vital sign

Cue and Clue
Anamnesa Physical Examination Anemic konj. (+/+) Lab

Probl List
Anemia Normocitic Normochromi c

Idx
ANN e.c 1. Chroni c diseas e 2. bleding

PDx
Benzidine test Blood Morphology Reticulocyt e

PTx
Blood transfusion PRC 1 colf

Pmo
Full blood check

Hb
Eryt juta/ul MCV MCH MCHC

9,3 g/dl
2,91 93,8 31,9 34,1

Cue and Clue
Anamnesa Flank pain The volume of urine was decrease

Probl List
Renal Failure

Idx
Acute Renal Failur e

PDx
Lab Ureum Crea USG Abdomen

PTx
Inf. RL 12 tpm Furosemide 1 x 1

Pmo
Urine output volume Ureum creatinin

Physical Examination Costovertebrae angle pain (+/+)
Lab Ureum Crea

Chroni c Renogram Renal Failur Urinalisis e UTI

126 7

Thank You