CR Nephrolithiasis Dx - Dr Akhada M. Sp.U
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Transcript of CR Nephrolithiasis Dx - Dr Akhada M. Sp.U
CASE REPORT
HYDRONEPHROSIS GRADE III-IV ET CAUSA
URETROLITHIASIS
Supervisor:
Dr. Akhada Maulana Sp.U
By :
L. Karisma Aditya
H1A 008 003
IN ORDER TO UNDERGO THE CLINICAL ORIENTATION /
CLERKSHIP AT THE SURGERY FUNCTIONAL MEDICAL STAFF
MEDICAL FACULTY OF MATARAM UNIVERSITY
NTB GENERAL HOSPITAL
2013
CASE REPORT
I. Patient Identity
Name : Mr. Y
Sex : Male
Age : 53 years old
Address : Sape, City of Bima
Religion : Moeslem
Race : Mbojo
Occupation : Farmer
Relationship status : Married
Date of hospital admission : August 23th 2013
Date of examination : August 26th 2013
II. Anamnesis
The chief history : difficult to urinate
Present disease history :
Patient complained difficult to urinate since 1 months ago. The complaint worsen for
the past 1 weeks. Micturition hesistency (+) and the urine were suddenly stop in the middle of
urinate that flow again with positional change. Patient complained right flank pain since 1
months ago. The patient said that the pain was dull and sometimes referred to upper
abdomen, penis, and scrotum. He felt pain periodically and disturb his activities. The pain
was not associated by position and activity. Color of urine is yellow, clear, and frequency 4-5
times a day. History of fever (+), nausea (-), vomiting (-). Micturition complaints: History of
pain during micturition (+), blood urinate (-), wake up at night to urinate (-), sandy and stone
urinating (+) 3 years ago.
Patient only eat small amount of food for 3 times a day. Drink about 1.5 L per day,
doesn’t drink coffee. Defecation was normal, once daily, concistency firm and brown.
Past disease history:
The history of stone and stone urinating (+) 3 year ago and blood urinate (-). Hypertension
(-), diabetes mellitus (-), asthma (-), uric acid (-), urinary tract infection (+).
Family disease history:
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No family member with the same complaint. Hypertension (-), diabetes mellitus (-), asthma
(-),uric acid (-)
Drug allergy : food (-) and drug (-)
History of treatment :
Patients was referred from General Hospital Bima, where the patient was hospitalized
for 8 days and a history of catheter placement in the city hospital bima (+). Patients often
seek treatment for back pain to the general practitioners and only was injectable analgetic
medication. Patient had a history of Pulmonary TB and had been treated with
Antituberculosis medication for 6 months. He said that he has been cured from TB.
Private and Social History :
Patient has a wife with 6 children and 3 grandchildren. He likes soft drink with
carbonated. He drank 1.5 liters of water a day. History of smoke (-), coffe consumption (-).
III. Physical Examination
General condition : Good
Consciousness/GCS : compos mentis/E4V5M6
A. Vital Sign
Blood pressure : 110/80 mmHg
Heart rate : 68 bpm
Respiration rate : 20 rpm
Temperature : 36.3oC
B. General Status
Head and neck
o Head : normochepali, deformity (-)
o Eyes : anemic (-/-), icteric (-/-), pupil isocore 3mm/3mm, pupil reflex (+/+)
o Noise : deformity (-)
o Mouth : cyanotic (-)
o Neck : enlargement lymph node (-)
Thorax
o Inspection: chest wall shape and size simetric, mass (-), lesion (-), retraction
(-), thoracoabdominal respiration (+).
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o Palpation: chest wall movement simetricly, tenderness (-), vocal fremitus (+/+)
normal, mass (-), crepitation (-).
o Percussion: sonor in both lung, percussion pain (-).
o Auscultation :
Pulmo : vesicular in both lung (+/+), rhonchi (-/-), wheezing (-/-)
Cor: S1S2 single, regular, murmur (-), gallop(-)
Abdomen
o Inspection : distention (-), mass (-)
o Auscultation : bowel sound (+) normal
o Percussion : timpani in whole region
o Palpation : tenderness (-), H/L/R not palpable, defans muscular (-), mass (-),
ballotement (-)
Upper and Lower extremity:
Warm acral (+/+/+/+), Deformity (-/-/-/-), oedem (-/-/-/-).
C. Urogenitalia physical examination
Costo vertebrae angle (CVA) region:
o Inspection: color same as the surrounding skin, mass (-), inflammation (-), scar
(-), hematome (-), bulging (-/-)
o Palpation : tenderness (-/-), mass (-), ballottement (-)
o Percussion : pain (-/-)
Suprapubic region
o Inspection: color same as the surrounding skin, mass (-), inflamation (-), scar
(-), sistostomy (-)
o Palpation : bladder distention (-), mass (-), tenderness (-)
Genitalia externa:
o mass (-)
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IV. Summary
Patient, male, 53 years old, complained difficult to urinate since 1 months ago.
Micturition hesistency (+) and the urine were suddenly stop in the middle of urinate that flow
again with positional change. The patient complained right flank pain since 1 months ago, he
said that the pain was dull and sometimes referred to upper abdomen, penis, and scrotum. He
felt pain periodically and disturb his activities. There were no micturition complaints. Patient
only eat small amount of food for 3 times a day. History of fever (+), micturition (+),sandy
and stone urinating (+) 3 years ago. Drink about 1,5 L per day, doesn’t drink coffee.
Defecation is normal. On the physical examination, there were tenderness on the CVA
region, and pain on the percussion.
V. Working diagnosis
Suspect right renal stone
VI. Differential diagnosis
Right ureter stone
VII. Propose Examination
CBC
Urinalysis
BNO-IVP
USG Abdomen
VIII. Laboratory Examination
Parameter April 26th 2013 RANGE
WBC 9,39.103/ul 4-11
RBC 4,66.106 /ul 4,5-5,5
Hb 11,6 g/dl 13-18
HCT 35,8 % 37-50
MCV 95,3 fl 82,0-92,0
MCH 30,5 pg 27,0-31,0
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MCHC 32,0 g/dl 32,0-37,0
PLT 451.103/ul 150-400
BT 2’00” <6”
CT 5’30” <15”
GDS 85 mg/dl <160
Creatinin 1,2 mg/dl 0,9-1,3
Ureum 27 mg/dl 6-26
SGOT 20 mg/dl <40
SGPT 21 mg/dl <41
HbsAg non reactive
Albumin 3,5-5
Urinalysis result (February 23rd 2013)
pH : 6,5
color : yellow
leukosit : +2
nitrogen : N
protein : -
glukosa : -
urobilinogen : N
keton : -
bilirubin : -
eritrosit : -
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Hydronephrosis grade III – IV dextra
Thorax Rontgent Result
Interpretation :
Susp. Pulmonary TB relaps.
VIII. Diagnosis
Hydronephrosis Grade III-IV et causa Uretrolithiasis dextra.
IX. Planning:
o Pro Urethrolithotomy + Dj Stent
X. Prognosis:
Quo ad vitam : bonam
Quo ad functionam : dubia ad bonam
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