By: Melita Handayani 0808121229

Identity: Name : Mrs. R Sex : Female Age : 54yo Occupation : Farmer Address : Kampar Kiri Admission to the hospital on August 25th 2012

 Right

flank pain since 2 days before admission to the hospital

 Since

2 days before admission the patients complained pain on the right flank. The pain described as a low intensity, continously and no reffered

 Since

3 months before admission patient already have the same type of flank pain Frequent voiding (+), cant hold to have voiding (+), pain when voiding (-), bloody urine (-), lessed force of the urine stream (), intermittension voiding (+), terminal dribbling (+), 3-4 times voiding at the night, cloudy urine history (+),

 Fever

(+), nausea (+), vomit (+), decrease appetite (+), rather difficulty of defecation.

 Hypertension

(+) Diabetes melitus (-)

 No

family with the same illness

 General

condition : moderately illness Conciousness : composmentis Vital sign

BP P RR T

: 130/80 mmHg : 60 x/1 : 20 x/1 : 36,3 0C

 Head

and neck : conjuntiva anemia (-/-), sclera icteric (-/-), mucosa of mouth and lips dry (-) Chest : normal Abdomen : normal Extremity : skin turgor normal, warm, well perfused Genitourinary : localized

 Urological

Status
CVA Scar Inflamation RIGHT LEFT -

Tenderness
Knock pain Ballotement

+
+ +

Suprapubic Inspection Palpation

Region
: Scar (-), Inflamation(-) : bladder unpalpable

 Right

flank due to right renal stone

 Right

renal pain due to acute pyelonephritis

 Urinalysis Routine

Blood Renal function Uric acid IVU USG of renal, urether and bladder

 Routine HGB WBC HCT PLT Routine GLU BUN CRS Ureum

Blood
: 11,5 gr/dL : 24,5 x 103/uL : 33 % : 359 x 103 /uL

Urine
107 mg/dL 26 mg/dL 1,95 mg/dL 55,6 mg/dL

IVU
Multiple opacity on right paravertebra L1-2

Nephrogram Phase
Media excress left and righ

Passage well

Cystogram

Voiding phase

 Right

staghorn stone with right hydronephrosis grade III-IV

 IVFD

RL 30 gtt/1 Inj. Ceftriaxone Plan to Bivalve Nephrolithotomy