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1. MORNING
REPORT
Sunday, 2nd July, 2023

2. Identity
● Name : Mrs. E
● Age : 58 years old
● Gender : Female
● Weight : 80 kg
● Address : Batu
● Arrival Date : 2nd July 2023
● Patient Type : Non Trauma

3. ANAMNESIS
Main Complaint:
The patient came to the emergency room at 16.45 WIB. The patient complained of pain in the right back that
radiated to the right front abdomen with a VAS score of 4-5. The pain had started 3 months ago and the patient
had gone to the poly and was diagnosed with kidney stones and was advised for surgery but the patient still
refused due to fear. The pain has been getting worse since the afternoon before SMRS. Dizziness (-) Nausea
(-), vomiting (-), fever (-), pain (-)
Illness history :
DM (+) controlled, HT (+), Uric acid (+)
Family History: -
Medicine History:
Allupurinol 1 x 100mg
Candesartan 1 x 16mg
Glimepride 1 x 4mg
Tamsulosin 1 x 0.4mg
Pipemidic acid 1 x 400mg
Cefixome 1 x 100mg
PCT 1 x 500mg

4. GENERALIST STATUS
Consciousness : Composmentis
GCS : 456
BP : 156/88 mmHg
HR : 92 x/minute
RR : 23 x/minute
SpO2 : 96% on RA
Tax : 36.8 c

5. PHYSICAL
EXAMINATION
HEAD/NECK:
Head
Eyes: Anemic conjunctiva (-/-), icteric sclera (-/-), Isochor
pupil diameter 3mm/3mm, Light reflex direct and indirect +/+
Ears : bloody Otorea (-/-)
Nose : epistaksis (-/-)
Neck :
Inspection: tracheal deviation (-)
Palpation: enlarged lymph nodes (-)
Auscultation : Bruits (-)
THORAX :
Cor:
Inspection: ictus cordis invisible
Palpation: ictus cordis palpable at ICS 5 MCL S
Percussion: Right heart border at ICS 4 PSL D, Left heart
border at ICS 5 MCL S
Auscultation: S1 S2 single regular, murmur (-), gallop (-)
Pulmo:
Inspection: normal chest wall shape, retraction (-)
Palpation: symmetrical D/S chest wall movement
Percussion: sonor
Auscultation:
R
h
-
-
-
-
-
-
Wh -
-
-
-
-
-
Ves +
+
+
+
+
+

6. PHYSICAL EXAMINATION
Abdomen
Inspection: Soefl, inflammation (-) scar (-) eritem (-),
distended (-)
Auscultation : Bowel Sounds (+) N, 12x/mnt
Abdominal Percussion: Tympani
Abdominal Palpation: Defans muscular (-), Superficial
and profundus pain :
- - -
+ - -
- - -
Extremity:
Dry red warm akral +/+/+/+, CRT< 2, Pitting oedem
in the legs (+/+)
Localist status:
Urogenital
Renal
Inspection: Distended (-), scar (-)
Palpation: CVA pain (+/-), tenderness (+/-)
Auscultation: bruit a.renalis (-)
Suprapubic
Inspection: Bulging (-), eritem (-), scar (-)
Palpation: Tenderness (-)
Percussion: Tympani

7. PROBLEM LIST & PLANNING
Problem list Definitive Diagnosis Planning
Diagnosis
Planning Therapy
Main Complaint:
• The patient complained of pain in the right back that
radiated to the right front abdomen with a VAS score of 4-5
• CVA pain (+/-), pain of the ren’s palpation (+/-)
Past medical history:
DM (+), HT (+), Uric Acid (+)
Lab results (2/7/2023):
P-LCR 29.5 H
Urinalysis
Nitrit (+1)
Bakteri (+3)
Kolik ureter
Batu ureter
Hidronefrosis D HT
EKG
DL, FH, Ur/Cr,
AU, Antigen,
GDA
BOF
USG Abdomen
CT Scan
Abdomen
- IVFD RL 20 tpm
- Inj ketorolac 30 mg
- Inj ranitidin 50 mg
- Ceftriaxone 2x1
- Ketorolac 3x1
- As traneksamat 3x500
- Dulcolax supp
- Fasting 8 hours pre-OP
- URS DJ Dextra

12. THANK YOU