Urology Case Presentation

RIGHT RENAL STAGHORN STONE WITH

HYDRONEPHROSIS AND HYPOKALEMIA

BY:
Hanan Afifah
H1A 012 019

SUPERVISOR:
Dr. Akhada Maulana, Sp. U

IN ORDER TO UNDERGO THE CLINICAL ORIENTATION/

CLERKSHIP AT THE SURGERY FUNCTIONAL MEDICAL STAFF
MEDICAL FACULTY OF MATARAM UNIVERSITY
NTB GENERAL HOSPITAL
2016

CASE PRESENTATION
1. Patient Identity
Name
Sex
Age
Address
Religion
Race
Occupation
Reationship status
Date of hospital admission
Date of examination

: Mrs. J
: Female
: 40 years old
: Selong
: Islam
: Sasak
: Housewife
: Married
: April 2nd 2016
: April 7th 2016

2. Anamnesis
- Chief Complaint : Right flank pain
- Present disease history :
Patient referred from Namira hospital Selong with right flank pain
because of suspect right stones kidney. This pain was felt since 1 year ago
and get worse in the last 3 months. Patient felt an intermittent pain and it
came suddenly while patient takes activities. Patient felt the pain was
sharply and was not spread to stomach, pubic region, and groin. This pain
was not affected by position of the body.
The urine color is yellowish, clear, with frequency 3-5 times a day.
Micturition complaints like painful when urinate (-), unsatisfied sensation
after urinate (-), woken up at night because of feeling to urinate (-),
difficult to start urinating (-), bloody urine (-), stone urinate (-), sandy
urinate (-), faltered urination (-), heat urinate (-).
Defecation frequency 1 times a day, brown coloured, consistency
normal, bloody stool (-). History of fever (-), nausea (-), vomiting (-)
malaise (-), headache (-) and dizziness (+).
- Past disease history:

Patient said that she had hematuria around 1 years ago, the
hematuria happened only once, painless, and without any stone during
urinated. The history of hypertension (-), asthma (+), diabetes mellitus (-),
gastritis (+), urinary tract infection (-).
- Family disease history:
No family member with the same complaint. History of urinary
stones in the family (-), blood urinate (-), asthma (+), diabetes mellitus (-),
hypertension (-), gastritis (-).
- History drug Allergy: (-)
- History of treatment: - History of Habitually:
Alcoholic (-), active smoker (-) Soda-drinking habitual (-). Coffedrinking habitual (-).
3. Physical Examination
General condition
: Moderate
Consciousness/GCS : Compos mentis/E4V5M6
Vital Sign
- Heart rate
: 80 bpm
- Respiration rate
: 20 rpm
- Temperature
: 36,7C
- Blood pressure
: 110/70 mmHg
General status
Head and neck
- Head : normochepali, deformity (-)
- Eyes : anemic (-/-), icteric (-), pupil reflex (+/+) isocor
3mm/3mm.
Noise : discharge (-), rhinorea (-), deformity (-)
Mouth : cyanotic (-)
Neck : enlargement of lymphnode (-)

Thorax-Cardiovaskular
- Inspection
: mass (-), lesion (-), movement of chest wall
-

simetric, retraction (-).

Palpation
: movement of chest wall simetric, tenderness (-),

vocal fremitus (+) normal, mass (-).

Percussion
: sonor in both lung, percussion pain (-).
Auscultation :
2

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

wheezing (-/-)
Cor
: S1 S2 single, regular, murmur (-), gallop (-).
Abdomen
- Inspection
: distention (-), mass (-), scar (-)
- Auscultation : bowel sound (+), normal
- Percussion
: tympanic (+), pain (-)
- Palpation
: Hepar and lien unpalpable, pain (-)
Upper and lower extremity:
- Warm : + +
+ +
- Edema : - - Urogenital physical examination
- Costo vertebrae angel (CVA) region:
Inspection
: color same as the surrounding skin, mass

(-), inflammation (-), scar (-), hematoma (-), bulging (-/-)

Palpation
: tenderness (-/-), mass (-), ballotment (-/-)
Percussion
: CVA flank (+/-)
Suprapubic region
Inspection
: color same as the surrounding skin, mass
(-), inflammation (-), scar (-).
Palpation
: bladder distention (-), mass (-), tenderness

(-).
Genitalia externa
:
Secret (-), mass (-), inflammation (-), pain (-).
4. Summary
-

Patien, female 40 years old was reffered from Namira hospital

came to RSUP NTB with right flank pain. This pain felt since 1 year ago
and get worse in the last 3 months. Patient felt an intermittent pain and it
came suddenly while patient takes activities. Patient felt the pain is sharply
and was not spread to stomach, pubic region, and groin. This pain was not
affected by position of the body. The urine color is yellowish, clear, with

frequency 3-5 times a day without micturition complaints. Patient said that
she had hematuria around 1 years ago, the hematuria happened only once,
painless, and without any stone during urinated
Physical examination of the results obtained
-

Blood Pressure : 110/70 mmHg mmHg, pulse : 80 beats per minute,

RR : 20 times per minute, Temperature : 36,7 oC

- Costo vertebrae angle (CVA) region :
Percussion CVA pain (+/-)
Palpation : tenderness (-/-), mass (-), ballotment (+/-)
5. Working diagnosis
Suspect right renal stone with hydronephrosis
6. Differential diagnosis
Right ureter stone
Appendicitis
7.
8.

Plan Examination
Routine blood examination
Routine urine examination
Electrolyte examination
Abdominal ultrasonography
BNO Radiography
Abdominal CT-Scan
Laboratory Examination (April, 4th 2016)
DL
Parameter

Result

HB
HCT
WBC
PLT

13,2 g/dl
40,5%
8,78 . 10^3/Ul
340 . 10^3/Ul

CHEMICAL
Parameter
GDS
SGOT
SGPT
Ureum
Kreatinin
Asam Urat

Result
98 mg %
16 U/L
12 U/L
30 mg %
0,6 mg %
4,9 mg %

ELECTROLITE
Parameter

Result

Na
K
Cl

138 mmol/L
3,3 mmol/L
104 mmol/L

9. Abdominal CT-Scan

10. Interpretation
- Appear the multiple staghorn stone in the right kidney with a size 3.28
cm x 1,17 cm and 0,49 cm x 0.81 cm.
-

Ren sinistra in normal range

Doesnt seem stone on the right and left ureter

Bladder within normal limits

Lien and pancreas in normal range

11. Conclusion
- Staghorn stone ren dextra with hydronephrosis dextra.
- Hypokalemia
12. Diagnose
Right renal staghorn stone with hydronephrosis and hypokalemia
13. Planning Therapy

Correction hypokalemia until kalium >3,5 with drip KCl 10 mEq/100

mL RL.

Pro Extended Pyelolitotomi dextra

14. Prognosis
-

Qou ad vitam :dubia ad bonam

Quo ad functionam : dubia ad bonam

10