CASE REPORT

HYDRONEPHROSIS GRADE III-IV ET CAUSA

URETROLITHIASIS

Supervisor:

Dr. Akhada Maulana Sp.U

By :

L. Karisma Aditya

H1A 008 003

IN ORDER TO UNDERGO THE CLINICAL ORIENTATION /

CLERKSHIP AT THE SURGERY FUNCTIONAL MEDICAL STAFF

MEDICAL FACULTY OF MATARAM UNIVERSITY

NTB GENERAL HOSPITAL

2013

CASE REPORT

I. Patient Identity

Name : Mr. Y

Sex : Male

Age : 53 years old

Address : Sape, City of Bima

Religion : Moeslem

Race : Mbojo

Occupation : Farmer

Relationship status : Married

Date of hospital admission : August 23th 2013

Date of examination : August 26th 2013

II. Anamnesis

The chief history : difficult to urinate

Present disease history :

Patient complained difficult to urinate since 1 months ago. The complaint worsen for

the past 1 weeks. Micturition hesistency (+) and the urine were suddenly stop in the middle of

urinate that flow again with positional change. Patient complained right flank pain since 1

months ago. The patient said that the pain was dull and sometimes referred to upper

abdomen, penis, and scrotum. He felt pain periodically and disturb his activities. The pain

was not associated by position and activity. Color of urine is yellow, clear, and frequency 4-5

times a day. History of fever (+), nausea (-), vomiting (-). Micturition complaints: History of

pain during micturition (+), blood urinate (-), wake up at night to urinate (-), sandy and stone

urinating (+) 3 years ago.

Patient only eat small amount of food for 3 times a day. Drink about 1.5 L per day,

doesn’t drink coffee. Defecation was normal, once daily, concistency firm and brown.

Past disease history:

The history of stone and stone urinating (+) 3 year ago and blood urinate (-). Hypertension

(-), diabetes mellitus (-), asthma (-), uric acid (-), urinary tract infection (+).

Family disease history:

2

No family member with the same complaint. Hypertension (-), diabetes mellitus (-), asthma

(-),uric acid (-)

Drug allergy : food (-) and drug (-)

History of treatment :

Patients was referred from General Hospital Bima, where the patient was hospitalized

for 8 days and a history of catheter placement in the city hospital bima (+). Patients often

seek treatment for back pain to the general practitioners and only was injectable analgetic

medication. Patient had a history of Pulmonary TB and had been treated with

Antituberculosis medication for 6 months. He said that he has been cured from TB.

Private and Social History :

Patient has a wife with 6 children and 3 grandchildren. He likes soft drink with

carbonated. He drank 1.5 liters of water a day. History of smoke (-), coffe consumption (-).

III. Physical Examination

General condition : Good

Consciousness/GCS : compos mentis/E4V5M6

A. Vital Sign

Blood pressure : 110/80 mmHg

Heart rate : 68 bpm

Respiration rate : 20 rpm

Temperature : 36.3oC

B. General Status

Head and neck

o Head : normochepali, deformity (-)

o Eyes : anemic (-/-), icteric (-/-), pupil isocore 3mm/3mm, pupil reflex (+/+)

o Noise : deformity (-)

o Mouth : cyanotic (-)

o Neck : enlargement lymph node (-)

Thorax

o Inspection: chest wall shape and size simetric, mass (-), lesion (-), retraction

(-), thoracoabdominal respiration (+).

3

o Palpation: chest wall movement simetricly, tenderness (-), vocal fremitus (+/+)

normal, mass (-), crepitation (-).

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

o Auscultation :

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

Cor: S1S2 single, regular, murmur (-), gallop(-)

Abdomen

o Inspection : distention (-), mass (-)

o Auscultation : bowel sound (+) normal

o Percussion : timpani in whole region

o Palpation : tenderness (-), H/L/R not palpable, defans muscular (-), mass (-),

ballotement (-)

Upper and Lower extremity:

Warm acral (+/+/+/+), Deformity (-/-/-/-), oedem (-/-/-/-).

C. Urogenitalia physical examination

Costo vertebrae angle (CVA) region:

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

(-), hematome (-), bulging (-/-)

o Palpation : tenderness (-/-), mass (-), ballottement (-)

o Percussion : pain (-/-)

Suprapubic region

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

(-), sistostomy (-)

o Palpation : bladder distention (-), mass (-), tenderness (-)

Genitalia externa:

o mass (-)

4

IV. Summary

Patient, male, 53 years old, complained difficult to urinate since 1 months ago.

Micturition hesistency (+) and the urine were suddenly stop in the middle of urinate that flow

again with positional change. The patient complained right flank pain since 1 months ago, he

said that the pain was dull and sometimes referred to upper abdomen, penis, and scrotum. He

felt pain periodically and disturb his activities. There were no micturition complaints. Patient

only eat small amount of food for 3 times a day. History of fever (+), micturition (+),sandy

and stone urinating (+) 3 years ago. Drink about 1,5 L per day, doesn’t drink coffee.

Defecation is normal. On the physical examination, there were tenderness on the CVA

region, and pain on the percussion.

V. Working diagnosis

Suspect right renal stone

VI. Differential diagnosis

Right ureter stone

VII. Propose Examination

CBC

Urinalysis

BNO-IVP

USG Abdomen

VIII. Laboratory Examination

Parameter April 26th 2013 RANGE

WBC 9,39.103/ul 4-11

RBC 4,66.106 /ul 4,5-5,5

Hb 11,6 g/dl 13-18

HCT 35,8 % 37-50

MCV 95,3 fl 82,0-92,0

MCH 30,5 pg 27,0-31,0

5

MCHC 32,0 g/dl 32,0-37,0

PLT 451.103/ul 150-400

BT 2’00” <6”

CT 5’30” <15”

GDS 85 mg/dl <160

Creatinin 1,2 mg/dl 0,9-1,3

Ureum 27 mg/dl 6-26

SGOT 20 mg/dl <40

SGPT 21 mg/dl <41

HbsAg non reactive

Albumin 3,5-5

Urinalysis result (February 23rd 2013)

pH : 6,5

color : yellow

leukosit : +2

nitrogen : N

protein : -

glukosa : -

urobilinogen : N

keton : -

bilirubin : -

eritrosit : -

6

BNO-IVP result

7

Conclusion :

Proximal Uretrolithiasis in line VL-4, size 1,2 cm x 0,5 cm.

8

Hydronephrosis grade III – IV dextra

Thorax Rontgent Result

Interpretation :

Susp. Pulmonary TB relaps.

VIII. Diagnosis

Hydronephrosis Grade III-IV et causa Uretrolithiasis dextra.

IX. Planning:

o Pro Urethrolithotomy + Dj Stent

X. Prognosis:

Quo ad vitam : bonam

Quo ad functionam : dubia ad bonam

9