Morning Report

November 17 , 2017 th

Dept. of surgery
G26
Daftar OB Bedah

Ny. R 52 th Cholelithiasis + Nephrolithiasis

An. D 11 th OF Radius & Ulna S 1/3 Distal
Sdr K 29 th Contusio Muscle & tendon
Ny. W 51 th Nephrolithiasis Dextra et Sinistra
Sdr B 21 th Vulnus App Kulit Kepala + Vulnus App
Cubiti
Identity

Name : Mrs W
Age : 51 years old
Address : Bungur RT 2 RW 2 Sugiharjo- Sukodadi
Admission : November 16 th, 2017 at 19.35
 Chief Complaint

Abdominal Pain
Present history

Patients complained of abdominal pain since 2 weeks before

admission. She feel abdominal pain at epigastric through the
waist. Pain feel disappear, healed with medication but it relapsed
again after the drugs effect run out. Patient also complain red
urination, but never dysuria, anyang-anyangan, urine with
stone. Normal defecate. Eat and drink as usual, patients also felt
nauseous + but not vomiting -. Patients do not complain of chest
pain nor dyspneu -. Last meal at 15.00.
 Past history of Illness

Hypertension-
Diabetes-

Family history : -
Vital Signs

Blood Pressure
128/82 mmHg
Temp
37.1 0 C
RR
22 x/min
Pulse
129x/min, strong, reguler
 GCS 456
K/L: aicd
Tho : sim/sim
Cor : S1 S2 single, murmur -, gallop
Pulmo : ves/ves, rh -/-, wh -/-
Abdomen
Inspection
Soefel
Auscultation
Met -, bowel sound + WNL
Palpation
Liver/Spleen within normal limit, tenderness
Percussion
Tymphany
Nyeri ketok CVA +/+
CLUE AND CUE

Female, 51 years old

GCS 456
Abdominal pain
Et regio epigastrik and flank
Red urination
Nyeri ketok CVA+/+
Assesment

Colic Renal
Planning Diagnose

Complete Blood Test

BOF
Laboratory Findings

Gula Darah Acak --> Hasil : 104 [ ]

Ureum 50 [15-43]
Serum Creatinin 2.3 [0.7-1.2]
.metode 1 --> Hasil : Non Reaktif [ Non Reaktif ]
.Hbs Ag --> Hasil : Negatif [ Negatif ]
Lekosit --> Hasil : 11.8 [ 4.0 - 11.0 ]
Neutropil --> Hasil : 71.9 [ 49.0 - 67.0 ]
.Limposit --> Hasil : 21 [ 25.0 - 33.0 ]
Monosit --> Hasil : 4.9 [ 3.0 - 7.0 ]
Eosinopil --> Hasil : 1.0 [ 1.0 - 2.0 ]
Basofil --> Hasil : 1.2 [ 0.0 - 1.0 ]
Laboratory Findings

.Eritrosit --> Hasil : 3.25 [ 3.80 - 5.30 ]

.Hemoglobin --> Hasil : 8.8 [ P13,0 - 18,0 ; L14,0 -18,0 ]
Hematokrit --> Hasil : 26.5 [ L 40 -54 ; P 35 - 47 ]
MCV --> Hasil : 81.5 [ 87.00 - 100 ]
MCH --> Hasil : 27.1 [ 28.00 - 36.00 ]
MCHC --> Hasil : 33.20 [ 31.00 - 37.00 ]
RDW --> Hasil : 12 [ 10 - 16.5 ]
Trombosit --> Hasil : 565 [ 150 - 450 ]
MPV --> Hasil : 4 [ 5 - 10 ]
.Laju Endap Darah 1 --> Hasil : 117 [ 0 - 1 ]
.Laju Endap Darah 2 --> Hasil : 119 [ 1 - 7 ]
BOF
Re-Assesment

Nephrolithiasia Dextra et Sinistra

Anemia
 Planning Therapy

USG
Inf PZ loading1000cc maintenance pz 500 cc/24
jam
Inj Antrain 3x1g iv
Inj Ranitidin 2x50mg
Inj Ceftriaxon 2x1g iv
Transfusi PRC 2 kolf
C/ Sp.U
PLANNING MONITORING

GCS
Vital Signs
Patients complaint
Planning Education

Explain to the patient dan her family about the disease,

cause, complication, intervention of the therapy and
prognosis