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Patients identity
Name
:Siti Muhaiyah Sex :Female Age :54 years old Religion : Islam Ethnic : Banjar Address : makmur mulia village, satui Occupation : housewife Hospitalized since :july, 16th,2013
ANAMNESA
Main Complain: flank pain History of Present Illness:
The flank pain occured since 2 weeks ago. It appears suddenly , intermittent and there wasnt spread of pain anywhere. The patient had intermittent fever one week ago. The patient felt nausea and watery vomitted 5 times a day. The patient had decrease appetite. The frequency of urination was normal and theres no pain during the process. The volume of urine was decrease.The patient feels theres some sand in her urine. The stool was normal. When she was young, the patient got a ureter stone operation.
Other illness: HT (-), Urinary tract infecton (-)
Physical Examination
GCS : 4-5-6 Weight : 45 kg Height : 150 BMI : 20,0 kg/m2
Vital Sign Blood presure : 140/80 mmHg, measured at right arm, when patient lying down, using aneroid sphygnomanometer. Pulse : 80x/minutes, reguler and strong Respiratory rate : 20x/minutes, thoraxoabdominal Temperature : 36,2oC, measured using
Physical Examination
Head and Neck
: Bruit (-), Increasing of JVP (-), enlargement Lymph (-) : Anemic konjunctiva (+/+), icteric : Rh (-), Wh (-). : S1-S2: single, murmur (-) : Flat. Hepar, lien, and mass unpalpated. No dullness. Costovertebrae angle pain -Abdominal pain.
+ + +
Extremitas
Laboratory Finding
Hb
Leu
Eryt Ht
MCV
MCH MCHC
Ureum
Crea
9,3 g/dl 11,9 ribu/ul 2,91 juta/ul 27,2 vol% 93,8 31,9 34,1 126 7
PROBLEM LIST
1. Susp Urolithiasis
2. 1st Grade Hypertension 3.Anemia Normochromic Normocitic 4. Acute Renal Failure
Cue and Clue Anamnesa Flank pain Sand in urine History of Nephrolithiasis operation Physical Examination Costovertebrae angle pain (+/+)
Probl List
Idx
PDx
PTx
Pmo
HT grade 1
HT grade 1
Furosemide 1 x 1
-Vital sign
Probl List
Anemia Normocitic Normochromi c
Idx
ANN e.c 1. Chroni c diseas e 2. bleding
PDx
Benzidine test Blood Morphology Reticulocyt e
PTx
Blood transfusion PRC 1 colf
Pmo
Full blood check
Hb
Eryt juta/ul MCV MCH MCHC
9,3 g/dl
2,91 93,8 31,9 34,1
Probl List
Renal Failure
Idx
Acute Renal Failur e
PDx
Lab Ureum Crea USG Abdomen
PTx
Inf. RL 12 tpm Furosemide 1 x 1
Pmo
Urine output volume Ureum creatinin
126 7
Thank You