Urology Assesment

Patient Identity

Name : Tn. X
Sex : Male
Age : 53 y.o.
Birth : 16 January 1967
MRN : 445-26-88
 Anamnesis
Chief complaint:
Left flank pain since 1 month ago
History of present illnesses:
• Drinking about 600 ml of
bottled water per day after being
diagnosed with Chronic Kidney
Disease since 7 months ago
• Left flank pain since 1 month ago
• The pain was dull, radiate (-),
intermittent, and affected by changes
of position (-)
• Fever (-), nausea (-), or vomiting (-)
• Bloody urine (-), cloudy urine (-),
sandy urine (-), and passing stones
out of the genital (-)
• Unemployed for the last few months
 Anamnesis

History of past illnesses:

• Chronic Kidney Disease Stage V on hemodialysis every Monday and
Thursday at Persahabatan Hospital (September 2019)
• Diabetes (-), high blood pressure (-), heart disease (-), gout (-), and
allergies (-)
 Physical Examination
Body weight 62.4 kg, body height 167 cm, body Thorax: simetric
mass index 22.37 kg/m2 Cardiac: normal heart sound, regular,
Compos mentis murmur (-), gallop (-)
Pulmo: vesicular breath sound, wheezing (-),
Blood pressure: 134/114 mmHg rhonki (-)
Heart rate: 94 times/minute Abdomen: flat, normal bowel sound, no
Respiration rate: 18 times/minute tenderness, tympanic
Temperature: 36 C Urology Status
Right flank: no scar, no mass or bulging, CVA
General Status test (-)
Left flank: no scar, no mass or bulging, CVA test
Head: normocephalic (+)
Eyes: anemic conjunctiva (-), icteric sclera (-) Supra symphysis: no scar, no mass or bulging,
no tenderness
Neck: lymph node enlargement (-)
External genitalia: no abnormalities
 Laboratory Findings (08/04/20)

CBC: 10.8/34.1/6550/267000
Ur/Cr: 101.4/15.8
SGOT/SGPT: 13/11
PT/APTT: 0.9x/1x
Na/K/Cl: 142/3.9/104.9
Uric acid: 8.6
Random blood glucose: 137
HBsAg: reactive
Anti HCV: non-reactive
Urinalysis: yellow, clear/ pH 7.5/ specific
gravity 1.015/ leu 40-45/ ery 20-22/ bacteria
(+)/ nitrite (-)/ esterase leucocytes (1+)
Urine culture: Streptococcus alphahemolytic
 Kidney-bladder USG (13/04/20)

Right kidney:
Cyst with dimension of 46.4 x 37.2 mm, no stone, no mass, no
hydronephrosis
Left kidney:
Cyst with dimension of 29.7 x 19.4 mm, mild hydronephrosis, no stone,
no mass
RK LK

VU
 Without Contras CT Urography (13/04/20)

• Cystic lesions fill the parenchyma of both kidneys

• Multiple stones in the upper and lower minor calix of both kidneys as
well as the left ureteropelvic junction, diameter ranges from 2 - 13
mm, attenuation of HU 913-1434
• Hydronephrosis of the left kidney
• Cystic lesion on segment VIII of liver
 Working Diagnosis
• Multiple right kidney calyces stones, with the largest size of 13 x 13 x 16
mm
• Multiple left kidney calyces stones, with the largest size of 13 x 13 x 16
mm
• Left kidney ureteropelvic junction stone, with the size of 12 x 12 x 16 mm
• Polycystic kidney disease
• Mild left hydronephrosis
• CKD stage V on HD
• Hepatitis B
 Management Plan

• Left RIRS
• Hepatology Division of Internal Medicine consultation
Thank You