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IDENTITY

Name : Mr. M
Age : 52 years old
Admission : August, 7th 2017
DPJP : dr. Muh. Jabir, Sp.U
HISTORY TAKING
Main complaint : the right abdominal pain
Anamnesis :
The patient was refference from kolaka hospital with the complaint was a
right abdominal pain that going through the backside that he felt since 2
weeks ago. The pain come with an epigastric pain. Nausea (+), vomitting (-),
fever (-). The patient also have a pain when defecating and a black stool
with soft consistency. The urinating is normal.
He has a history of a nefrolithiasis operation at 2015.
PHYSICAL EXAMINATION

General State :
Moderate ill, conscious
Vital Sign :
BP : 150/90mmHg
RR : 20x/m
HR : 84x/m
T : 37,30c
GENERALIZED STATUS

Head : Normally Extremity


Face : Normally Superior : Normally
Eyes : conjungtiva anemis +/+ Inferior : Normally
Nose : Normally
Mouth : Normally
Ears : Normally
Neck : Normally
Chest : Normally
Abdomen : Normally
STATUS UROLOGI
Regio costovertebralis dextra
Inspeksi : skin town is same with around, Regio suprapubic
Inflammatory sign (-) hematom (-) Inspeksi : flattening, tumor mass (-), hematom (-)
Palpasi : Tumor mass (-) ballotemen test (-) Palpasi : tenderness (-)
tenderness (-)
Perkusi : tap pain(+)
Regio costovertebralis sinistra
Inspeksi : skin town is same with around,
Inflammatory sign (-) hematom (-)
Palpasi : Tumor mass (-) ballotemen test (-)
tenderness (-)
Perkusi : tap pain(-)
Regio genitalia eksterna
Penis inspeksi Penis is circumcised, OUE on the tip of the penis
palpasi tenderness (-)
Scrotum inspeksi The color is darker than its surroundings
palpasi two normal testis impression, tenderness (-)
Perineum inspeksi skin town is same with around, tumor mass (-)
palpasi tenderness (-)
Rectal toucher > Sphincter ani suffocating, Slippery mucosa, Prostate is not palpable, tumor
mass (-)
handscoen black stool (+) mucus (-) blood (-)
CLINICAL FINDING
LABORATORY FINDINGS
PARAMETER RESULT

GDS 89 mg/dl

BLOOD CHEMISTRY TEST Ureum


Creatinine
47 mg/dl
1,9g/dl
August 7th 2017 SGOT/AST 16U/L
SGPT/ALT 15gr/dl
HBsAg Non Reaktif

PARAMETER RESULT

ROUTINE BLOOD TEST WBC 11,93x 103/uL

August 7th 2017 RBC


HB
2,60x 106/uL
5,9g/dL
PLT 355x 103/uL
RADIOLOGY FINDINGS

Ginjal kanan: multiple echo batu uk 0,6 cm, dilatasi PCS


(-)
Hepar, GB, lien, pankreas, ginjal (s) dan VU dbn
Kesan : nefrolith dextra
DIAGNOSIS

Colic abdomen ec.


Nefrolith dextra
MANAGEMENT
IVFD
Antibiotic
Analgetic
H2R antagonis
Consult a urologi Surgeon