IDENTITY

Name : Mrs. H
Age : 50 years old
Address : Lambandia
Admission : Dec, 9th 2018
Doctor in Charge : dr. Laode Rabiul Awal, Sp.B K-BD
 HISTORY TAKING
• Main complain : Left waist pain
• Anamnesis
Suffered since 1 day ago before admitted to the hospital. Pain was sharp and
intermittent. There was pain when urinate and urine like thick tea since 3 days ago.
There was no fever, nausea and sandy urine history. Defecate was normally.
There was no history same complaint
History of medication : analgetic
PHYSICAL EXAMINATION

The patient was conscious with moderete ill

BP = 150/90 mmHg Pulse = 100x/m,

RR = 20x/m, regular Temperature = 36,5oC

Generalized status

• Head : Normal • Abdomen: Localized state

• Face : Normal • Extremity
• Eyes : Normal • Superior : Normal
• Nose : Normal • Inferior : Normal
• Mouth : Normal
• Ears : Normal
• Neck : Normal
• Chest : Normal
LOCALIZED STATUS
Abdominal
-Inspection: convex, follow the motion of Rectal Touche
breath Sphincter: Tight
-Auscultation : Peristaltic was normal Mucosa : slick and smooth
-Palpation : Tenderness (+) at region lumbal Ampulla : Empty
dextra, mass (-), renal ballottement (-) Prostate : Normally
-Percussion: There was tympany sound, tap Handscoen : Feces (-), Blood (-), Mucus (-)
pain (+)
Suprapubic
-Inspection : Distended (-)
-Palpation : Tenderness (-), mass (-)
Clinical Finding
 DIAGNOSIS
Colic abdomen e.c susp. Ureterolithiasis
 PLANNING

USG abdomen
Routine blood, and urinalysis
USG

-Hidronefrosis sedang kanan curiga et

cause ureterolithiasis
- Multipel cholelitiasis
LABORATORY FINDINGS
PARAMETER RESULT

WBC 14,33 x 103/uL

HB 13,0 g/dL
PLT 260x 103/uL

PARAMETER RESULT REFERENCE

GDS 98 mg/dl 70-180

Ureum 30 mg/dl 19-44
Creatinin 1 mg/dl 0.7-1.2
MANAGEMENT
IVFD
Analgetic
H2R Antagonist
Antibiotic
Consult Surgeon