Vesikolithiasis

+
Cystitis

Hadiyanto Tiono
Fakulty of medical Krida wacana
Adviser : Dr. Sjaiful B. Sp.B

Patient Identity

Name
Sex
Age
Education
Work
address
keji 4/3

: Mr. U
: Male
: 17 years old
: Senior High School
: Student
: Kp bojong

ANAMNESIS
Chief Complain:

Pain during urination

since 1 year ago

History of Disease
Patient came to complain of any pain during
urination since a year ago, the pain is felt
intermittent, urine is not smooth, the
emission is Not strong, and feels hot, stone
(-).
The change Of position to make a smooth
urination. blood (-). Fever (+), low back pain
(-),
normal defecation

History of pass illness

(-)
family history of disease
(-)

Physical Examination
General state
Awareness
BP
Pulse

: moderate illness
: compos mentis

: 120/70 mmHg
: 76x/minute

Temperature : 38,9 C
RR

: 22 x/minute

Status localist a / r Abdomen

Inspection
: flat, no visible lump / mass
in the
suprapubic
Palpation : no palpable mass or lump in the
suprapubic, suprapubic
tenderness (+)
Percusion : CVA -/-

Digital rectal examination

Tonus sfingter Ani strong,
Ampula not colaps
normal limit mucosa,
No palpable mass at the 12 oclock
At handscoen no visible feces or blood.
Hipertrofi Prostate (-)

Differential Diagnosis

Vesikolithiasis + cystitis
UTI
Striktur uretra
Uretero lithiasis

Support Examination
URINALISIS
USG

Working DIAGNOSIS

VESIKOLITHIASIS +
Cystitis

URINALISIS
Warna
: Kuning
Kerkeruhan : Agak keruh
Berat Jenis : 1,025
Ph
: 6,0
Leukosit
: +++
Nitrit
:+
Protein
: ++
Glukosa
: normal
Benda keton : Uronilinogen : normal
Bilirubin
:Eritrosit
: ++++

Sedimen
Eritrosit: 15-20
Lekosit : 5- 8
Silinder : Kristal : Bakteri: +
Jamur : -

TREATMENT
Planning operation

PROGNOSIS
Ad Vitam : Bonam
Ad Functionam : Bonam
Ad Sanationam : dubia ad bonam