Morning Report

20-05-2019
 Patient Identity
• Name : Mr. AG
• Age : 25 yo
• Sex : male
 Anamnesis
• Main Complain : Lower right back pain since 2 months ago
• Current History: The patient is a referral patient from Kalabahi Hospital with
a diagnosis of Hematuria ec. Susp. Vesicolithiasis. Patients present with
complaints of lower back pain that occur 2 months before being hospitalized.
Pain is felt sharply as if it were cut suddenly appeared and settled
throughout the day. Pain felt increased when the patient was seated and
reduced when the patient slept with his back position propped up with a
pillow. Complaints of patients then increasingly heavy as time goes by until 3
weeks ago the patient begins to urinate blood. Blood urine is fresh red
without pain when urinating or having difficulty urinating. Pain is only felt in
the patient's lower right back. The patient then just checked into the
Kalabahi Hospital 2 weeks after blood urinary complaints. The patient was
then referred to RSU WZ Johaness to get treatment for a urologist. Patients
had complained of fever. Complaints of nausea vomiting and others are
denied.
• history of habits : patients have the habit of
drinking water <1.5 L per day (cooking water),
patients have the habit of drinking alcohol 2-3
times a week and drinking coffee 1-2 glasses
per day. habit of holding urine (+)
• Treatment History:
Treatment from Kalabahi Hospital:
– Inj. Kalnex 3 x 500 mg IV
– Inj. Antrain 3 x 40 mg IV
 Physical Exam
Vital Sign :
Blood preasure : 120/80 mmHg , Pulse: 86 times/minute
reguler, Temperature : 37,7 C, RR : 22x/minutes ,CRT <2
seconds, SpO2 99 %
GCS : E4V5M6 (15)
Head : Normocephal
Eye : pupil isokor (+/+), Direct and Indirect Ligth Reflex
(+/+), pale conjungtive (+/+), icteric scelra (-/-)
Ear : ottorea (-/-)
Nose : blood clot (-/-), rhinnorea (-/-)
Thorax : chest expansion bilateral simetric, Vesicular (+/+),
rhonci (-/-), wheezing (-/-).
• Abdomen
• Inspection :flat,distended (-),lesion(-)
• Palpation : tenderness on right
hipocondriac region, CVA pain (+/-) mass
(-)
• Percusion : timpany sound (+)
• Auscultation : peristaltics (+) still
normally

• Genitalia : Catheter (+), browny red

color, thick, volume 100cc
 LABORATORY

• Hb : 6,8 g/dl Urinalisa :

Color: Reddish
• HCT : 19,0 % yellow
• WBC : 15,23 x 103/ul Purity : Bloody
Leukosit Esterase :
• PLT : 324 x 103/ul 2+
• Blood Glucose : 103 Protein : 2+
mg/Dl Blood : 2+
Sedimen :
• BUN : 48 mg/dl Erythrocyte : Full
• Cr : 6,63 mg/dl Leukocyte : Full
Epitel : Full
BNO X-Ray

Expertise : Bladder
stone
 Assesment
• Haematuria ec. Vesicolithiasis
 Therapy
• IVFD RL 20 tpm
• Inj. Omeprazole 2 x 40 mg
• Inj. Ketorolac 3 x 30 mg
• Inj. Kalnex 3 x 500 mg
• PRC Transfusion
• Consult for Urologist
TERIMA KASIH