Identity

• Name : Lilik Khusniyah

• Age : 31 th
• Sex : Female
• Register: 12453270
• Address : Wonokitri Buntu 88
• Occupation : house wife
• Admission : 27-10-15
• Insurance : BPJS 3
• Organ : kidney
• Doctor : Hasroni (HFR)
 Anamnesis
• Patien consulted by digestive with abscess psoas D post op appendic perforation +
moderate HN D + right ureter stone
• Chief complain : Right lower abdomen mass
• Patient suffered right lower abdomen mass 3 weeks ago. The patient feel that pain
almost all the time. History of flank pain (+), haematuria (+), stone expulsion (+)
since 1996, fever (+), nausea (-), vomiting (-).
• History of HT and DM denied
• History of surgery:
• 1 st operation : Laparotomi (infra umbilical incision) ec appendix perforation
(8/9/15), dr Guruh, Sp. B at Brawijaya Hospital
• 2nd operation: advice dr SIS  URS D in Haji hospital by RAL (20/10/15) (patient
refuse to open diversion)
During operation, impacted ureteral stone, difficult to inserted URS further and SJ
stent, 2 hour  stop operation
 Physical examination
• General condition : fair
• BP 110/70 mmHg, Pulse 80 x/m, RR 20 x/m
• General State
• H/N : A - / I - / C - / D -
• Thorax : cor S1S2 normal, pulmo ves/ves, rh -/-
• Abdomen : Flat, BS (+), H/L unpalpable, Right
inguinal mass, red, warm, size 4x4 cm
• Extremity : Edema (-), sensoric and motoric
normal
 Physical examination
Urological state
• Flank :mass -/-
• CVA knock pain : +/-
• Suprapubic : VU unpalpable
• GE : female,foley catheter 16 fr (+),
UP ± 1800 cc/24h, yellow clear
• DRE : Anal sphincter tone + normal, smooth
mucosa,
nodul (-), BCR (+)
Clinical Picture
 Laboratory Finding
Laboratoy, 27/10/2015
UL, 27/10/2015
Hb 10,4 g/dL pH 7,0
Leu 12,27 .103 /uL lekosit 1/lp
Tromb 385.103 /uL Erythrocyt 2/lp
FH PPT 12,7s e

APT 27,6 s BGA

T
SGOT/PT 48/54U/L pH 7,6
PCO 18
Alb 3.16 g/dL 2
BUN/SK 6/0,75 mg/dL PO2 143
CRP 71.8 ml/mg HCO 17,
3 7
Na/K/Cl 138,1/4.1/95,4/ BE -3,9
SO2 100
GDA 93 mg/dl
Thorax Photo 6/10/2015
Cor and Pulmo
with in normal
limit
 KUB 20/10/15
Radioopaque
shadow (-)
 CT scan abdomen with contrast
8/10/15
• Left ureteral stone with severe HN D
• Abcess iliopsoas D
CT scan abdomen with contrast
8/10/15
CT stonography
8/10/15
 CT IVU
8/10/15

• Lesi hypodense 9-23 HU, irregular, size 4,8 x 6,5 x

17,1 cm along m psoas mayor D PVL 1 until m
iliopsoas D extend to subcutan anterior abdomen
wall size 12,5 x 12,9 x 6,6 cm and extend to posterior
PVL 3-4 to m quadratus lumborum D and facia
thoracolumbar D size 4,7 x 4,4 x 4,05 cm
• Moderate Hidroureteronefrosis with nephrolithiasis
multiple at upper, mid and lower pole and multiple
ureter stone size 4 mm
• Incomplete left double system
 CT IVU
27/10/15
 CT IVU
8/10/15
 Interdepartement Consult
• Digestive : Drainage incision abscess at psoas
D, inguinal D region (CITO)
 Asessment
Working Dx : Abscess Psoas D
Primary Dx : Post appendectomy
perforation
Secondary Dx : Right Nephrolithiasis multiple
non opaque at upper, mid and
lower pole and multiple ureter
prox right stone post URS D,
Incomplete left double system
Complication : Right moderate
Dx hydronephrosis, non visualized
Right Kidney
 Planning
Suggest:
Dx: Urinary culture + SST, Uric acid
Tx: Inj Ceftriaxone 2x1 g
inj Metronidazole 3 x 500 mg
inj Metamizole 3x1 g
inj Ranitidin 2x50 mg

Plan : RPG-URS D + DJ stent D, if failed open diversi urine D

(after recovery from digestive operation)