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CASE REPORT

Colic Suspect Ureterolithiasis

CASE REPORT Colic Suspect Ureterolithiasis By: Irwinia Oktarini S. 07.06.0004 Supervisor: dr. Akhada Maulana, Sp.U IN

By:

Irwinia Oktarini S.

07.06.0004

Supervisor:

dr. Akhada Maulana, Sp.U

IN ORDER TO UNDERGO THE CLINICAL ORIENTATION / CLERKSHIP AT THE SURGERY FUNCTIONAL MEDICAL STAFF MEDICAL FACULTY OF UNIZAR NTB GENERAL HOSPITAL

2014

CASE REPORT

  • I. Patient Identity

Name Age Sex Religion Address Number of medical record Date of hospital admission Date of examination

: Mr. M : 35 years old : Male : Moslem : Lombok Utara : 097262 : January 27 th 2014 : January29 th 2014

II. Anamnesis Main complaint : right flank pain Present disease history :

Patient referred from KLU general hospital with suspect ureterolithiasis. Patient complained that he get right flank pain since 2 days before he came to the hospital. Pain refers to inguinal and lower abdominal. Colic pain, disuria. Frequency 4 times every day, cloudy urine (+), bloody urine (-). Fever (+) since 2 days ago, shivering (-), Patient also complained left flank pain since yesterday (28 th 2014). Not Defecation yet since 3 days ago.

He denied the history of bloody urine, nausea, vomitting, headache.

Past disease history :

The history of stone when urinate (+) 2 times at the 2 years ago, size ± 2 x 2 mm (like pulled rice) . The history of asthma (-), trauma (-), hypertension (-), diabetes mellitus (-)

Family disease history :

No family member with the same complaint. Asthma (-),hypertension (-),diabetes mellitus (-)

Drug allergy : (-) History of treatment : (-).

III.

Physical Examination

General condition Consciousness/GCS

  • A. Vital Sign

: Moderate : compos mentis/E4V5M6

Blood preasure

: 140/90 mmHg

Heart rate

: 80

bpm

Respiration rate

: 20 rpm

Temperature

: 36,5 o C

Nutritional status

: Normal

  • B. General Status Head and neck

o

o

Head

: normochepali, deformity (-)

o

Eyes

: anemic (-/-), icteric (-/-), pupil reflex (+/+)isocor 3 mm / 3 mm,

o

Noise

: deformity (-)

o

Mouth : cyanotic (-)

o

Neck

: enlargement of lymphnode(-)

o Thorax-Cardiovascular

o Inspection : mass (-),lesion (-), movement of chest wall simetric, retraction (-)

o Palpation : movement of chest wall simetric, tenderness (-), vocal fremitus (+) normal, mass (-)

o Percussion: sonor in both lung, percussion pain (-)

o Auscultation :

Pulmo : vesicular in both lung (+/+), rhonchi (-/-), wheezing (-/-)

o

Cor:S 1 S 2 single, regular, murmur (-), gallop(-) Abdomen

o

Inspection : distention (-), mass (-)

o

Auscultation : bowel sound (+), normal

o

Percussion : timpani in whole region

o

o

Palpation : mass (-), H/L/R unpalpable, defans muscular (-),enlargement of lymphnode(-), pressure pain (-).

Upper and Lower extremity:

Deformity (-), edema (-).

C. Urogenitalia physical examination Costo vertebrae angle (CVA) region:

o

o

Inspection: color same as the surrounding skin, mass (-), inflammation (-), scar

o

(-), hematome (-), bulging (-/-) Palpation : tenderness (+/+), mass (-), ballottement (-)

o

Percussion : pain (+/+)

o

Suprapubic region Inspection: color same as the surrounding skin, mass (-), inflammation (-).

o

o

Palpation : bladder distention (-), mass (-), pain (+).

o

Genitalia externa:

o

o Scrotum : enlargement (-), mass (-) o Penis : circumsicated, scar (-), urethral discharge (-), cateter inserted, OUP 500 cc at 5 hour. Rectal examination :

o Tonus spincter ani normotonik, empty ampulla recti, rectum mucose slippery, prostat palpable smooth, sulcus mediana palpable shallow, sulcus lateralis left and right lobus palpable, superior pole palpable, nodul (-), there is faeces in finger, yellow colour, blood (-).

IV. Summary

Patient reffered from KLU general hospital with suspect ureteral stone. Patient complained that he get right flank pain since 2 days before he came to the hospital. Pain refers to inguinal and lower abdominal. Pain like colic, disuria. Frequency 4 times every day, cloudy urine (+), fever (+), Patient also complained left flank pain (+), Not Defecation yet since 3 days ago.

General condition : Moderate, Consciousness/GCS : compos mentis/E4V5M6, blood preasure 140/90 mmHg, Heart rate 80 bpm, Respiration rate : 20 rpm, Temperature: 36,5 o C, nutritional status normal. In the physical examination, Costo vertebrae angle (CVA) region:

tenderness (+/+), pain (+/+), suprapubic region pain (+), genitalia externa: cateter inserted, OUP 500 cc at 5 hour.

  • V. Working Diagnosis Colic e.c Suspect Ureterolithiasis

VI.

Differential Diagnosis

Apendicsitis

Uretritis

Pielonefritis

VII.

Planing Examination

o

CBC, BUN, creatinin serum, Urinalysis

o

Abdominal Ultrasonography

o

BNO

o

IVP

VIII.

Laboratory Examination(January, 11 th 2014)

Parameter

27/01/2014

Hb

15,0

Creatinin

0,9

Ureum

18

SGOT

26

SGPT

24

WBC

11,23

PLT

201

 

Parameter

27/01/2014

Protein

+2

Erytrocyte

+4

Leukocyte

+2

IX.

USG result (January, 14 th 2014)

IX. USG result (January, 14 2014)
Volume BPH 84 cc + hidronefrosis grade I dextra suspec vesikuloureter refluks, urolithiasis (-). X. Theraphy

Volume BPH 84 cc + hidronefrosis grade I dextra suspec vesikuloureter refluks, urolithiasis (-).

X.

Theraphy

IVFD RL20 dpm Ceftriaxone inj 1gr/12h Antrain 1a/8h

XI.

Planning

ESWL

XII.

Prognosis

Quo ad vitam : bonam

Quo ad fungtionam : dubia ad bonam