Vera Oktapiani

Supervisor: dr. Marta Hendry, SpU

SURGERY DEPARTMENT MEDICAL FACULTY OF SRIWIJAYA UNIVERSITY

2013

PYELUM STONE RENAL DEXTRA

• Patient identification• Anamnesis• Physical examination• Laboratorium findings• USG• BNO-IVP• Diagnosis• Treatment• Prognosis• Case analysis

• Name : Mr. B• Age : 29 years old• Sex : Male• Address : Penukal• Nationality : Indonesian• Religion : Moslem • Occupation : farmer• Admitted : 12th June 2013• Medical Record: 728225

Chief Complaint: • Right flank pain 1 years before admitted to hospital

History of Present Illness:• Right flank pain, and the pain spreading to right

buttock.• The pain is intermittent but tend to settle• No pain when urinating • Hesitancy at the beginning of urinary flow,

decreased force and caliber of stream, and sensation of incomplete bladder emptying are denied

• No blood in the urine, and the patient didn’t know that he ever had stone or sand in urine

• Nausea, vomiting (-) and no abnormality in defecation

• Fever (-)

History of Past Illness:• No history of trauma at the stomach and back

bone area• No history of recurrent urinary tract infections• No history of surgery• No history of hypertension, diabetes mellitus• A little drink of water, and begin to drink lots of

water after he complaint about his pain

Family History:• History with same complaint as the patient in

family denied

General Examination(On 6th July 2013)

• Appearance : good• Consciousness : compos mentis• Blood pressure : 130/80 mmHg• Pulse rate : 70x/min• Respiratory rate : 20 x/min• Temperature : 36,60C• Eyes : Conjunctiva palpebra

anemic (-/-), sclera icteric (-/-), pupils isokor, light reflex (+/+)

• Neck : No abnormalities•  Thorax : No abnormalities• Heart : No abnormalities• Abdomen : refer to local examination• Genital : refer to local examination• Upper extremities : no abnormalities• Lower extremities : no abnormalities

Local Examination

CVA Region Right Left• Inspection : bulging (-) (-)• Palpation : ballottement (-) (-)• Percussion : percussion pain (+) (-) Suprapubic Region• Inspection : bulging (-)• Palpation : tenderness (-) External Genital Region• Inspection : bloody discharge (-) Rectal Toucher• TSA good, no enlargement of prostate, feaces (-), blood (-).

(21/6/13)Routine blood• Hemoglobin : 12,2 gr/dL (N : 14-18g.dL)• Hematocryte : 36 vol% (N : 40-48vol%)• Leucocyte : 7.600/mm3 (N : 5000-10000/mm3)• Thrombocyte : 227.000/mm3 (N : 200.000-500.000/mm3)•  Clinical Chemistry:• BSS : 81 mg/dL• Ureum : 25 mg/dL (N : 15-39mg/dL)• Creatinine : 0,86 mg/dL (N : 0,9-1,3mg/dL)• Na+ : 136 mmol/l (N : 135-155)• K+ : 4,5 mmol/l (N : 3,5-5,5)

Urine analysis (10/5/13):• Epitel cell : -/LPB• Leucocyte : 3-6/ LPB (N : 0-5 / LPB)• Erytrocite : 60-83/LPB (N: 0-1/LPB)• Silinder : -• Kristal : -• Bakteri : +• Muccus : -• Jamur : -

• No enlargement of prostate

• Accoustic shadow in renal dextra

Radio opaque appearance in right side between L1-L2, 1,8 cm in size

• Normal excretion of renal

• Radioopaque appearance in renal pyelum

• Pyelum stone renal dextra

• Pyelolithotomy

• Quo ad vitam : bonam

• Quo ad functionam : bonam

RIGHT FLANK PAIN

KIDNEY PROBLEMS

BACK AILMENTS

GASTROINTESTINAL PROBLEMS

KIDNEY PROBLEMS

• renal stone, • pyeloneprhitis, • polycystic kidney

disorders, • abscesses, • renal infarction• tumor

GASTROINTESTINAL PROBLEMS

MUSCLE SPASM

• Biliary colic• Cholecystitis

/choledocolitiasis

• Appendicitis

• No history of trauma can exclude muscle spasm

• no abnormality in defecation, nausea and vomit (-) can exclude gastrointestinal problems

• From physical examination, there is no abnormality in except pain on percussion in the CVA region.

• From laboratory, there is slightly decrease of haemoglobin, it because irititation renal wall by stone and make hematuria.

• The urynalisa prove the hematuria with the high level of eritrocyte.

• BNO-IVP and USG finding this patient is said to be diagnosed as pyelum stone.

• The risk factor in this patient is drinking habits. Little drink of water can higher the risk of kidney stone.

• Treatment for this patient is pyelolithotomy.

• Quo ad vitam prognosis is bonam and quo ad functionam prognosis is bonam.