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Morning Report

FEBRUARY

4TH, 2015

DOCTOR IN CHARGE: DR. PAUL A. DWIYANU SP.P

Group
Ekky Ardianto C.G
Abdul Latif
Devi Rahma Yulianti
Tika Nurullita

Patients Identity

Name
Sex
Age
Occupation
Address

: Mrs. Rusdiana
: Female
: 55 yo
: Wiraswasta
: Sei. Jelai Kec. Tambang
Ulang
Hospitalized since : February 3th, 2015

Summary of Data Base


Mrs.R/ 55 yo /Female (Autoanamnesis)
Chief Complaint : lumbar pain

Patient has lumbar pain since 1 day ago. Pain occur slowly and
heavier (score 5). Location of pain in left lumbar regio and
suprapubic. Patient felt nausea, vomit and gastric pain because of
anorexia. Patient also headache and dispnea.
History of Past illness: Hypertension, gastritis
History of Family illness:-

Physical Examination
General appearance

Looked moderately ill, Conscious, GCS : 4 5 6


H: 144 cm W: 55 kg IMT = 26 (Grade I Obesity)

Vital Signs

BP=120/90 mmH;PR=80 bpm regular, strong;RR=24 Tpm; T=36C axilla

Head

Pale conjunctiva (-/-), Jaundice sclera (-/-), Edema palpebral (-/-), Diplopia (-), discharge
(-/-), exophthalmus (-/-), lid retraction (-/-), lid lag (-/-)

Neck

Lymphatic node swelling (-), struma (-), bruit thyroid (-)

Chest Heart

Inspection : ictus invisible


Palpation : palpable in MCS ICS V
Right margin : Right : ICS 5 L.Ster (D).
Auscultation : S1 > S2 single, murmur (-) gallop (-)
Inspection : Symmetric, barrel chest (-)
Palpation : FV symmetric
Percussion :
Auscultation :
S | S
V |V
S | S
V |V
D | D
- |Wheezing (-), Rhonchi (-)
Inferior margin : D = ICS5
S = ICS6

Lung

Abdomen

Percussion:
D | D |D
D | D |D
D | D |D

Tenderness:
- |- |- |- |+
- |+|-

Extremities

Superior D & S : Edema (-/-), Pain (-/-), Weakness (-/-), tremor (-/-)
Inferior D & S : Edema (-/-), Pain (-/-), Weakness (-/-), tremor (-/-)

Laboratory findings
th 2015
January
19
Examinatio Value
Referred
Unit
n

Value

Examinatio
n

Value

Referred
Value

Unit

Hb

10

12,00-16,00

g/dl

GDS

101

<200

mg/dL

leukosit

15,5

4,0-10,5

th/ul

SGOT

19

0-46

U/I

eritrosit

3,86

3,90-5,50

million/ul

SGPT

17

0-45

U/I

hematokrit

29,3

37,00-47,00

Vol%

klorida

107,5

95-100

Mmol/l

Trombosit

253

150-450

th/ul

Ureum

133

10-50

Mg/dL

RDW-CV

14,6

11,5-14,7

Creatinin

6,1

0,6-1,2

Mg/dL

MCV

76,1

80,0-97,0

fl

MCH

25,9

27,0-32,0

pg

MCHC

34,1

32,0-38,0

Gran%

84,3

50,0-70,0

Limfosit%

10,1

25,0-40,0

MID%

5,6

4,0-11,0

Gran#

13,10

2,50-7,00

th/ul

Limfosit#

1,6

1,25-4,0

Th/uI

MID#

0,8

Th/uI

Problem list
Female, 55yo
1.Lumbar pain
1.1CKD

Data Support

Planning
Diagnosis

Planning therapy

Monitor

Education

vital sign
observation
Urine control

Bed rest
Diet
renal

Ax:
Vomit
nausea
dispnea
anemisz
abdominal pain
regio lumbar sinister
and suprapubic
History of past
illnes hipertension

USG
Abdomen
Lab (ureum,
creatinin,
darah rutin)

Confirm
Diagnosis
Ranitidin
Ketorolac
Cefriaxon
Inf. RL

Px
Konjungtiva anemis
Nyeri ketok ginjal

1.2 Urethrolithiatic

Abdominal pain
regio lumbar sinister
Nyeri ketok gnjal

Rontgen w/
contrast

Confirm
diagnosis
Inj Ketorolac
3x10mg
Ranitidin
Ceftriaxon
Inf RL

Vital sign
Urine control

Thank you

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