MORNING REPORT

IDENTITY

Name : Mr. H
Age : 40 years old
Sex : Male
Address : Bombana
Admission : October, 24th 2017
Doctor in Charge : dr. Muh. Jabir, Sp.U
 HISTORY TAKING

 Main complain : difficult urinate

 Anamnesis :
Suffered since 8 month ago, patient not satisfied when urinate.
Urine drips a little, weak emission, and patient feel pain during
urinate. The patien wakeup at midnight to urinate more than 5
times over night, and look like sandy in the urin.

There was no history of fever (-) , there was history blood urin (+),
There was no history of hypertension (-), diabetes (-)
 GENERALED STATE

Head : Normally
General Condition : Face : Normally
Moderate illness Eye : Normally
Conciousness : Nose : Normally
Composmentis, Mouth : Normally
Vital Sign : Ear : Normally
BP : 180/100 Neck : Normally
mmHg
Chest : Normally
RR : 20x/m
HR : 60x/m Abdomen : Normally
T : 36.70c Upper limb : Normally
Lower limb : Normally
 LOCALIZED STATE
 Regio costovertebralis dextra
Inspection : Inflammatory sign (-) hematom (-)
Palpation : mass (-) ballotemen test (-) tenderness (-)
Percussion : tap pain (-)
 Regio costovertebralis sinistra

Inspection : Inflammatory sign (-) hematom (-)

Palpation : mass (-) ballotemen test (-) tenderness (-)
Percussion : tap pain (-)
 Regio suprapubic

Inspection : flattening, mass (-), hematom (-)

Palpation : tenderness (+)
 Regio genitalia externa : normally
- Digital Rectal Examination (DRE)
Sfincter ani : tight
Mucosa : Smooth
Ampula : Empty
Handscoon : Blood (-), feses (-), mucus (-)
 PLANNING

Routine Blood
Blood Chemistry
Complete urine
BNO-IVP
 LABORATORY FINDINGS

ROUTINE BLOOD PARAMETER RESULT

TEST WBC
RBC
7.00x 103/Ul
4.98x 106/uL
SEPTEMBER 24th HB
PLT
14.3g/dL
237x 103/uL
2017
PARAMETER RESULT
BLOOD Ureum 31 mg/dl
CHEMISTRY TEST Creatinine 1.5 g/dl

SEPTEMBER 24th
2017
RADIOLOGY FINDING

October 23 2017

Vesikolithiasis diameter 44,2 mm

Cystitis kroni (11 mm)
 Diagnosis

Parsial retensi urin due to

Vesikolitiasis
+ Hypertension grade II
 MANAGEMENT

 IVFD
 Analgetics

 H2RA

 Consult a urology surgeon

THANK YOU