MORNING REPORT

September 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 Illness

Patient 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
Rectal

: MUE : bleeding (-)

: 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
Rntgen:
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