Morning report nefrolhitiasis

25 Juni 2011
Boby Hartanto Boy Harry Indah Putri

Patient j, male, 41 years old, came to the ED of AA hospital with the chief complaint is

right wrist pain since ten day before enter hospital.

History
since ten day before enter hospital pateint complaint right

wrist pain, pain is moderate and continously, not refer to right back or other site. Patien also feel fever, urinate colour change to red,red urine from beginning to end of urinate. there is nothing trauma on right wrist and then patient came to doctor dan given some drugs. The compaint is dissapear dan come back when drugs is up, then patient came to ED of AA hospital

Past illness history

Nefrolhitiasis history (-)
There is stone on urinate (-)

Familial illness history

There is nothing family that have same disease.

Generalized
Generalized condition : mild illness Conciousness : composmentis Vital sign : BP : 130/80mmHg RR : 20 x/minutes HR : 98 x/minutes T : 36,6 C

 Head and Neck Thorax Abdominal urogenital

Limph node

: normal : normal : normal : local status : no enlargement on palpation

Localized status
Regio lumbalis look : udem (-), scar (-) , inlamation sign (-) Feel : tenderness (+), ballotement (-)
Regio CVA Inflamation Scar Tenderness Knock pain dextra + + sinistra -

Laboratory Findings
Hb
White blood cel Trombosit haematocryte ureum CR-S Alb Glukose

: 11,0gr% : 5600/ mm3 : 247000 / mm3 : 33,2 % : 25,7 mg / dl : 0,6 mg / dl : 4,1 mg /dl : 97 mg/dl

Diagnosis
Nefrolitiasis dextra

Management
Pyelolythotomy