NEPHROLITHIASIS

+ TB ON OAT

By: Imam Sutanto

Supervisor
M. Diana Rahim, MD
 Patient Identity
Name : Mr.A
Age : 56 years old
Gender : male
No. RM : 168526
Admission Date : July 15 th 2021
 History Taking
Chief Complain: limp whole body
The patient came to emergency unit of Guntur Hospital with complaint of limp since 2 weeks before admission,
accompanied by nausea and abdominal pain, especially in the epigastrium and the left side of the abdomen. Cough and
runny nose are denied by the patient. The patient claimed that she does not have a history HT (-), DM (-), asthma (-), but
TB (+) is on treatment for 3 months and he undergoing treatment for nefrolithiasis. Out-of-town travel history (-),
contact history with confirmed covid-19 (-).
 Physical Examination
● General condition : moderate pain
● Awareness : composmentis
● GCS : E4M6V5
● TTV :

● Blood Pressure : 120/80 mmHg

● Pulse Rate : 92 bpm
● Respiratory Rate : 24 bpm
● Temperature : 36,2 oC
● SpO2 : 94% free air
Head : normochepal
Eyes : sclera icteric(-/-),conjunctiva anemic (-/-)
Nose : septum deviation (-), secret (-)
Ears : secret (-), edema (-)
Mouth : wet oral mucosa

Neck : lymph node enlargement (-)

Thorax : symmetrical chest movements

Cor : S1S2 regular, gallop (-), murmur (-)
Pulmo : VBS right/left, crackle (-/-),wheezing (-/-)

Abdomen : flat, supple, Bowel sounds (+) normal, epigastrium tenderness (+)
tenderness in right iliac(+)cva pain(+)
Liver : within normal limits
Spleen : within normal limits

Extremities : warm, CRT < 2 sec

● Blood Routine
● Hemoglobin : 11.8 gr/dl
● Leucocyte : 14.000 /mm3
● Hematocrite : 37,9 %
● Thrombocyte : 468.000/mm3
● Diff Count : 0/2/3/67/25/3
● NLR :-
● Bilirubin total : 1.87
● Bilirubin direk : 0,90

● Blood Chemistry
● Random Blood sugar :99 mg/dL
● Ureum : 84 mg/dL
● Creatinin :1.48 mg/dL
● SGOT : 107 U/L
● SGPT : 57 U/L
 Diagnostic

NEFROLITIASIS
TB PARU
PNEUMONIA
COVID 19
Management
IVFD Asering 20 tpm
Inj. Omeprazole 1 x 40 mg IV
Inj. Ondacetron 2 x 4 mg mg IV
Inj.keterolac 1 x 1 drip
Sucralfat syr 3 x 2
Metformin 1 x 1
Etambutol 2 x 1
 Managemen

dr, Ade sp.b

15/july/2021

Stop Rimpafisin
Curcuma 2x1
Hepamax 2x1
Cek ulang SGOT /SGPT
 16 july 2021
S: abdominal pain, especially in the epigastrium and the left side of the
abdomen
O: BP :109/73mmHg
RR : 20x/min
N :85
S :36,2
SpO2 95 % with 3 LPM
A: NEFROLITASIS,TB PARU ,SUP PNEUOMONIA COVID 19
IVFD Asering 20 tpm
Inj. Omeprazole 1 x 40 mg IV
Inj. Ondacetron 2 x 4 mg mg IV
Inj.keterolac 1 x 1 drip
Sucralfat syr 3 x 2
Hepamax 2x1
Curcuma 2x1

PLANNING:CEK USG ABDOMEN

16 JULY 2021 PCR (-)
 17 JULY 2021
BP :120/80mmHg
RR : 20x/min
N :112
S :36,4
SpO2 96 % with 3 LPM

 IVFD Asering 20 tpm

 Inj. Omeprazole 1 x 40 mg IV
 Inj. Ondacetron 2 x 4 mg mg IV
 Inj.keterolac 1 x 1 drip
 Sucralfat syr 3 x 2
 Hepamax 2x1
 Curcuma 2x1
 Katopren supp 2x1
SWAB PCR 2(-)
● URINE
BERAT JENIS : 1.O1O
BLOD : 3+
LEUCOSIT : 3+
PH :6

● SIDEMAN
LEUCOSIT : 4-7/LPB
ERITROSIT : 4-9/LPB
SEL EPITEL :1-2/LPB
 18 JULY 2021
BP :100/80mmHg
RR : 24x/min
N :112
S :36
SpO2 97 % free air

 IVFD Asering 20 tpm

 Inj. Omeprazole 1 x 40 mg IV
 Inj. Ondacetron 2 x 4 mg mg IV
 Inj.keterolac 1 x 1 drip
 Sucralfat syr 3 x 2
 Hepamax 2x1
 Curcuma 2x1
 19 july 2021

●there is an
improvement in the
condition of the
disease, it is
recommended
outpatient
Thank you