Departement of SURGERYPavilion shofa, 20th January 2015(14.00- 07.00 am)

IdentityName : Mr. FAge:39 YOSex : MaleAddress:Lamongan Date: 20 January 2015

AnamnesisChief complaint: left flank painPresent illnes: The patient complained about the pain in left flank area through to the back since 10 days ago. First, patient felt that the pain in right flank area move to the left flank area.This complaint accompanied by nausea (+), lower abdominal pain (+), vomiting (-), fever (-). Defecation was normale. Pain when urinating (+) and urine accompanied by sand (+) in this morning. Blood (-)

History of Pass Ilness :- Same complaint (+) 1 weeks ago in Soegiri- Acute of Hepatitis B (+)- CKD (+)

History of Family Illness :-

History of Sosial, Economic : - Smoking (+) 1 pack/days

History of Medication Alergic :- Asam mefenamat, metampiron, antalgin, ibuprofen

Physical ExaminationsGeneral Appearance : Compos mentisGCS : 456Vital sign :BP : 150/105 mmHgPulse : 110 bpmRR : 20x/minutesT : 36,5 C

Physic Examinations (General statue)Head & neck : Anemic-/ icteric-/ cyanosis-/ dyspneu-Thorax : simetric bilaterally, retraction (-/-)Pulmo: ves/ves, rh (-/-), wh (-/-)Cor: S1-S2 single, murmur(-), gallop(-)Abdomen: flat, soepel, mass (-), hepar and lien not palpable, meteorismus (-), bowel sound (+N),Extremity : akral hot, dry, red (+/+), edema (-/-)

Laboratory FindingsDiff count: 0/0/63/31/6Hematocrite: 42,0 %Hb 15,1 mg/dlLeukocytes : 12.000Thrombocyte : 353.000SGOT / SGPT 74/83Urea 50 mg/dlSerum creatinin 2,1 mg/dlBRG : 109

Chest X-ray

BOF

Clue and cueMale, 39 yoPain in left flank area through to the back since 10 days agoNausea (+), vomiting (-), fever (-)Pain when urinating (+)Lower abdominal pain (+)Urine accompanied by sand (+) BOF seen looks stone radioopaque in the urinary tract

- Urolithiasis Hepatitis B acuteDyspepsia Assessment

Planning Dx :BOF

Planning Tx :IVFD Asering 1500cc/ 24 hoursInj Ketorolac 3x1 amp ivInj Ranitidin 2x50 mg ivInj Ciprofloxacin 2x500mg p.oC / specialis urologiPlanning

PrognosisDubia ad bonamEducation Explain to the family about the condition of this patient now, its disease, about its examinations, theraphy and intervention will be done, and also about complication and prognosis.