Morning Report 8 September 2015 (Susp Urolithiasis)

MORNING REPORTSeptember 8th 2015

Coass : Ryan Arifin (I 11110011)

Case Of Emergency Department• Inpatients : 2• Ambulatory patients : 1• Total : 3• Time on Duty in IGD : 15.00 – 06.00 WIB

Outpatients. • An. F. 9 yo. VE digiti 5 Pedis Sinistra. Treatment : Wound

Toilet, Mefenamic Acid syr 3xCI, amoxycillin syr 3x1cth• Mr. M. 44 yo. Multiple VE. Treatment : Wound Toilet,

Mefenamic Acid 3x500 mg, amoxycillin 3x500 mg

Inpatient• Colic Abdomen. E.c. susp. Ureterolithiasis.

Identity• Name : Mr. I. • Gender : Male• Age : 32 years old• Religion : Christian• Address : Sui Ambawang

Chief Complaint• Left lower abdominal pain

History of Recent IllnessPatient came to ER with complain of left lower abdomen

pain that migrates to lower back 3 hours before admission. Pain is relieved with resting and exacerbated with activity.

Patient also complain with painful urination.the frequent of urination is often in the evening but the patient feel everytime he urinate, he feel not satisfied. Urine color normal. Defecating history is unremarkable.

Physical Exam• Status Generalis

• General Appearance : Light Illness• Conciousness : Compos Mentis E4V5M6• Vital Sign :

• RR : 24 x/minutes• HR : 88 x/minutes• BP : 130/100 mmHg• Temperature : 36,9 C

Physical Examination• Head : Normocephal• Eyes : Pupil isochor 3 mm, light reflex

(+/+), CA (-), SI (-).• ENT : bleeding (-)• Neck : tenderness (-)• Chest

• Cor : Heart sound S1,S2 regular, M(-), G(-)• Pulmo : VBS right=left, Wh-/-, Rh-/-

• Abdomen : soepel (+), tenderness (+) LLQ, bowel sound (+) N, injury (-)

Urological Status• Flank :

• Dextra : Ballotement (-) CVA stike tenderness (-) • Sinistra : Ballotoment (-) CVA strike tenderness (+)

• Suprapubic :• Tenderness (-) • Blast impression : empty

• Genital : MUE : bleeding (-)• Rectal : DRE not examined.

Working Diagnosis• Colic abdomen e.c. ureterolithiasis.• Dd. : Urinary Tract Infection

Additional Examination• Complete Blood Count• Ureum, Kreatinin.• Urinalysis• Kidney and Urinary Tract USG• Röntgen:

• BNO• IVP

Laboratory• Leucocyte : 12,3 x 103/dl• Erythrocyte : 5.22 x 103/dl • Hemoglobin : 14.8 g/dl• Platelet : 242 x 109/l• Blood Glucose : 124 mg/dl• Ureum : 24• Creatinine : 0.7• Uric Acid : 6,95

Urinalysis• Visual : Yellow• pH : 5• Protein : (+)• Erythrocyte : (+)• Leukocyte : (+)• Silinder : (-)• Crystal : (-)• Triple Phosphate : (++)

BNO

USG Abdomen• Liver and Pankreas normal.• Right Kidney normal.• Left Kidney : Slight hidronephrosis• Left ureter : proximal ureter stone, d : 1.3 cm.• Bladder : normal.• Prostate : normal.

Treatment• IVFD RL 20 drip per minute (infus set + abocath #20)• Ceftriaxone 1 gr / 12 hours IV• Ketorolac 30 mg / 12 hours IV• Pethidin 1 amp. Drip p.r.n.

Thank You