MORNING

REPORT
Sunday, 2nd July, 2023
Identity

● Name : Mrs. E
● Age : 58 years old
● Gender : Female
● Weight : 80 kg
● Address : Batu
● Arrival Date : 2nd July 2023
● Patient Type : Non Trauma
 ANAMNESIS
Main Complaint:
The patient came to the emergency room at 16.45 WIB. The patient complained of pain in the right back that radiated to
the right front abdomen with a VAS score of 4-5. The pain had started 3 months ago and the patient had gone to the poly
and was diagnosed with kidney stones and was advised for surgery but the patient still refused due to fear. The pain has
been getting worse since the afternoon before SMRS. Dizziness (-) Nausea (-), vomiting (-), fever (-), pain (-)
Illness history :
DM (+) controlled, HT (+), Uric acid (+)

Family History: -
Medicine History:
Allupurinol 1 x 100mg
Candesartan 1 x 16mg
Glimepride 1 x 4mg
Tamsulosin 1 x 0.4mg
Pipemidic acid 1 x 400mg
Cefixome 1 x 100mg
PCT 1 x 500mg
 GENERALIST STATUS
Consciousness : Composmentis
GCS : 456

BP : 156/88 mmHg

HR : 92 x/minute
RR : 23 x/minute
SpO2 : 96% on RA
Tax : 36.8 c
 PHYSICAL
EXAMINATION
THORAX :
HEAD/NECK:
Cor:
Head
Inspection: ictus cordis invisible
Eyes: Anemic conjunctiva (-/-), icteric sclera (-/-), Isochor
Palpation: ictus cordis palpable at ICS 5 MCL S
pupil diameter 3mm/3mm, Light reflex direct and indirect +/+
Percussion: Right heart border at ICS 4 PSL D, Left heart
Ears : bloody Otorea (-/-)
border at ICS 5 MCL S
Nose : epistaksis (-/-)
Auscultation: S1 S2 single regular, murmur (-), gallop (-)
Neck :
Pulmo:
Inspection: tracheal deviation (-)
Inspection: normal chest wall shape, retraction (-)
Palpation: enlarged lymph nodes (-)
Palpation: symmetrical D/S chest wall movement
Auscultation : Bruits (-)
Percussion: sonor
Auscultation:

Ves + + Wh - - Rh - -
+ + - - - -
+ + - - - -
 PHYSICAL
EXAMINATION
Abdomen Localist status:
Inspection: Soefl, inflammation (-) scar (-) eritem (-), Urogenital
distended (-) Renal
Auscultation : Bowel Sounds (+) N, 12x/mnt Inspection: Distended (-), scar (-)
Abdominal Percussion: Tympani Palpation: CVA pain (+/-), tenderness (+/-)
Abdominal Palpation: Defans muscular (-), Superficial Auscultation: bruit a.renalis (-)
and profundus pain :
- - - Suprapubic
Inspection: Bulging (-), eritem (-), scar (-)
+ - -
Palpation: Tenderness (-)
- - - Percussion: Tympani
Extremity:
Dry red warm akral +/+/+/+, CRT< 2, Pitting oedem
in the legs (+/+)
 PROBLEM LIST & PLANNING
Problem list Definitive Diagnosis Planning Planning Therapy
Diagnosis
Main Complaint: Kolik ureter EKG - IVFD RL 20 tpm
• The patient complained of pain in the right back that Batu ureter DL, FH, Ur/Cr, - Inj ketorolac 30 mg
radiated to the right front abdomen with a VAS score of 4-5 Hidronefrosis D HT AU, Antigen, - Inj ranitidin 50 mg
• CVA pain (+/-), pain of the ren’s palpation (+/-) GDA - Ceftriaxone 2x1
BOF - Ketorolac 3x1
Past medical history: USG Abdomen - As traneksamat 3x500
DM (+), HT (+), Uric Acid (+) CT Scan - Dulcolax supp
Abdomen - Fasting 8 hours pre-OP
Lab results (2/7/2023): - URS DJ Dextra
P-LCR 29.5 H

Urinalysis
Nitrit (+1)
Bakteri (+3)
THANK YOU