A Case Report

Urolithiasis
PRECEPTOR:
dr. Ginanda Siregar, Sp.U

COMPOS

ER

S:
Carvin Herryanto

110100204

Kyna Troeman

110100115

Devandran Mahendran

110100403

Pieter Lumbanraja

110100366

Try Yudia Ramadhany

110100118

Choky Lumban Gaol

110100338

Angelia Sitanggang

110100277

Regina Tambunan

110100097

Puvana Subramaniam

110100503

Hemakanen Nair

110100413

CLINICAL SENIOR WORK

GENERAL REFERENCE CENTRE HOSPITAL HAJI ADAM MALIK
SURGERY DEPARTMENT
MEDICAL FACULTY OF SUMATERA UTARA UNIVERSITY
MEDAN
2016
TABLE OF CONTENT

Title................................................................................................................

Table of Content...........................................................................................

Chapter 1 Preliminary.................................................................................

1.1. Background......................................................................................

Chapter 2 Literature Review......................................................................

2.1. Urinary Stone Formation Process....................................................

2.2. Type Stone Tract..............................................................................

2.3. Clinical Manifestations and Evaluation...........................................

11

2.4. Management of Urinary Tract Stone................................................

13

Chapter 3 Case Report................................................................................

18

Chapter 4 Discussion...................................................................................

23

Chapter 5 Conclusion..................................................................................

25

Reference......................................................................................................

26

CHAPTER 1
PRELIMINARY
1.1.

Background
Urinary tract stone disease is the third most common cause of pain the

urinary tract after infection and pathological disorders of the prostate. This disease
is a common disease that is often found in both animals and humans. Naming
concerning tract stone disease Urinary influenced by a variety of disciplines 1.
Urinary tract stones are a form of polycrystalline aggregates that formed
by a variety of crystalloid and the organic matrix. There several types of urinary
tract stones are the main basis of the components constituent namely: calcium
oxalate stones, calcium phosphate stones, struvite stones, Uric acid stones and
cystine stones. Urinary tract stones can be anywhere in the urinary tract such as
the kidney, ureter and bladder 2.
Stone formation is influenced by the concentration of urine depends the
urine pH, ion content in the urine, the solute concentration and others. Some other
factors that affect the formation of stones in human factors such as age, sex, race,
geographic location, diet and fluid consumption, use of drugs and the presence or
absence of disease broadcaster. Family history is also one of the factors which
25%
patients have a family with a history of urinary tract stone disease 2.
In Indonesia, urinary tract stone disease still occupies portions the largest
number of patients in the urology clinic. From the data ever published found an
increasing number of patients with kidney stones got action in RSUPN-Cipto
Mangunkusumo from year to year started 182 patients in 1997 to 847 patients in
2002.3

CHAPTER 2
LITERATURE REVIEW
2.1.

Urinary Stone Formation Process

Urinary tract stones are polycrystalline aggregates that formed from a

variety of crystalloid and the organic matrix. Stone formation is influenced by the
saturation of urine. Saturation of urine depends the urine pH, ions, solute
concentration, and others. The relationship between the concentration of solutes
with stone formation very clear. the greater the concentration of ions, the ions will
then chance settles will be higher. If the ion concentration increases, ion will reach
a point called solubility product (Ksp). When ion concentration rises above this
point, it will begin the process crystal growth and nucleation.

Figure 2.1. Stages saturation of urine

Source: Campbell-Walsh Urology 10th Edition. Urinary lithiasis. Pearle, M.

Nucleation theory asserts that urinary tract stones are formed from crystals
or foreign objects from urine levels are saturated. However, stones are not always
formed from a high patient or excretion rate at risk of dehydration. The theory of
crystal inhibitor is another theory on stone formation. According to this theory, the
stone was formed because of the low the concentration of ions into a natural
inhibitor of the stone like magnesium, citrate and pyrophosphate. However, the
validity of this theory is still questionable, because many people are deficient ions
are not impaired urinary tract stones 1
The main ingredient is the stone-forming crystalline component. There
several stages in the formation of crystals that nucleation, growth, and
aggregation. Nucleation is the beginning of a process of stone formation and
influenced by a variety of substances such as proteinaceous matrix, objects
foreign, and other particles. Heterogeneous nucleation (epitaxy) is a type of
nucleation common in the rock formation. This is due to heterogeneous nucleation
requires less energy than homogeneous nucleation. A type of crystal will be a
nidus for nucleation Other crystal types, such as uric acid crystals would be a
nidus for nucleation of calcium oxalate 1
Components of the rock matrix varies depending on the type of stone.
Matrix components typically only 2-10% of the weight of the stone. The
composition of the matrix is the dominant protein with little hexose or
hexosamine. The role of the matrix in the initiation of stone formation is still not
known perfectly. The matrix can serve as a nidus for aggregation of crystals or as
adhesive components of small crystals 1.
Normal urine contains a chelating agent such as citrate, which inhibit
nucleation, growth and aggregation crystals containing calcium ions. Other
inhibitors are calgranulin, Tamm Horsfall protein, glycosaminoglycans,
uropontin, nephrocalcin, and other. The biochemical mechanism of the
relationship between these substances with stone formation is still not fully
understood, but when the examination of the substance of the levels are below
normal, then there will be aggregation of crystals that will form a stone 4.

Nephrocalcin, glycoproteins that are acidic and secreted by the kidneys, can
inhibit nucleation, growth and aggregation of calcium oxalate 5
Urinary tract stones are usually formed from a combination of factors, and
rarely are formed from a single crystal. Stones more often established in patients
with a high consumption of animal protein or less fluid consumption. Stone also
be formed from metabolic condition such as distal renal tubular acidosis, Dent's
disease, hyperparathyroidism, and hyperoxalouria 4
2.2.

Type Stone Tract

1. Stone Calcium
Calcium is found in food are absorbed as much as 30-40% in 10% of the

small intestine and is absorbed in the colon. Calcium absorption varies depending
on the calcium intake. Calcium is absorbed in phase Ionic, and the absorption of
calcium is not perfect because of the establishment complex calcium in the
intestinal lumen. The substance that can produce complex calcium is phosphate,
citrate, oxalate, sulphate and fatty acids 5.
Calcification can take place and accumulate in the duct collecting,
producing urinary tract stones. Approximately 80-85% of the whole incident of
stone is calcium stones. Calcium stones are very often caused by increased levels
of calcium in the urine, increase in uric acid levels in the urine, increased levels of
oxalate and decreased citrate in the urine 1
Hypercalciuria is a disorder most commonly found in patients with
calcium stones. However, the role of hypercalciuria on stone formation is still
controversial. Last investigation states that plaque is a potential precursor to the
formation of stones calcium and the scores are directly related to the levels of
calcium in and the incidence of urinary stones. 5. The concentration of calcium in
a high urine causes increased saturation of calcium salts in urine and decreased
activity inhibitors such as citrate and chondroitin sulphate 1.

a. Absorptive Hypercalciuric nephrolithiasis

Normal calcium consumption on average per day is 900-1000 mg.
Approximately 150-200 mg to be excreted through the urine. Absorptive
hypercalciuria (AH) is a state of increased absorption of calcium in the small
intestine, especially jejunum. It is caused by increased the amount of calcium that
is filtered by the glomerulus, resulting in suppression of parathyroid
hormone. Furthermore, calcium reabsorption in the renal tubules will decreased,
resulting in hypercalciuria. This is a physiological cascade in response to the
increase in calcium absorption in the small intestine. 1
AH is divided into three types: type I, II, and III. Type I AH is independent
of diet and constitute 15% of all cases of calcium stones. At AH type I, there are
increased levels of calcium in the urine despite do dietary calcium
restriction. Type II AH is a cause of stone urinary tract are quite common and
dependent on diet. In type II AH, normal calcium excretion on the restriction of
dietary calcium. Patients should limit calcium intake of about 400-600mg /
day. Type III AH caused leakage of phosphate in the kidneys. The reduced
phosphate levels lead increased synthesis of 1, 25-dihydroxyvitamin D.
Physiological cascade will increase the absorption of phosphate and calcium in the
intestines and increasing calcium excretion from the kidneys, resulting in
hypercalciuria 5.
b. Resorptive Hypercalciuric nephrolithiasis
About half of the patients with primary hyperparathyroidism Experienced
urinary tract stones. Patients with calcium phosphate stones, women with
recurrent calcium stones should be suspected to have hyperparathyroidism.
Hypercalcemia is a common sign of hyperparathyroidism. Hormone Parathyroid
produce elevated levels of phosphorus in urine and decreasing levels of
phosphorus in plasma, followed by rising Plasma and urinary calcium.
c. renal hypercalciuria
The kidneys filter about 270 mmol of calcium and do reabsorption of more
than 98% of them to maintain homeostasis calcium. Approximately 70% of
calcium reabsorption in the proximal tubule underway. The calcium reabsorption

takes place paracelular. In renal hypercalciuria, renal tubular damage cause

disturbances in calcium reabsorption. This causes increased levels of calcium in
the urine. Serum calcium levels remain caused normal renal calcium loss is
compensated by increasing calcium absorption and mobilization of calcium via
the digestive of bone caused by the increase of parathyroid hormone 5.
d. Hyperoxalouric calcium nephrolithiasis
Hyperoxalouric calcium nephrolithiasis caused by increased levels of
oxalate in the urine is above 40 mg in 24 hours. Usually it is found in patients
with inflammatory bowel disease, chronic diarrhea and severe dehydration and
rare caused by the consumption of excess oxalate. Chronic diarrhea that causes
malabsorption resulting increased levels of fats and bile. Intraluminal calcium
binds with fat, causing sponifikasi process. calcium levels Low cause calcium
should bind oxalate decreased. Oxalate-free ready to be absorbed and not affected
by inhibitors. Increased absorption of oxalate resulted in an increased formation of
calcium oxalate product. This resulted in the potential for the occurrence of
nucleation and crystal growth 5.
e. Hypocitraturic calcium nephrolithiasis
Citrate is an important inhibitor of urinary tract stones. Rising demand in
mitochondrial metabolic kidney cells causes decreased excretion of urine. This
occurs in acidosis metabolic, hypokalemia, fasting, hypomagnesemia, androgen
and gluconeogenesis 5.
When forming complexes with calcium, would lower the concentration of
calcium and decreased energy for nucleation. citrate also inhibit agglomeration,
spontaneous nucleation and crystal growth of calcium oxalate and reduce levels of
monosodium urate 5.
2. Stone Struvite
According to Griffith in Sellaturay, struvite stones formed from
magnesium, ammonium and phosphate. First discovered by Ulex, a geologist
from Sweden in the 18th century. The name 'struvite' comes from diplomats and
Russian scientist HCG von Struve. Brown found that the bacteria will break down
urine and facilitate stone formation. Proteus vulgaris he isolated from the core

stone now known as secrete urease. Struvite stones are commonly found in
women and often recurs in a short time. Other microorganism that break down
urea and can cause struvite stone is Proteus, Pseudomonas, Providencia,
Klebsiella, Staphylococci, and Mycoplasma. High ammonia levels of these
organisms resulting in alkalynization of the urine pH up MAP 7.2 so that crystals
will precipitate 1.
To form struvite stones, urine should contain ammonia and trivalent
phosphate ions at the same time. Renal tubular only produce when organisms
excrete ammonia acid, but trivalent ion phosphate is not available at the time the
urine is acidic, therefore stone struvite not formed during physiological
conditions. In pathological conditions, where there are bacteria which produce
urease, urea will be broken into ammonia and carbonic acid. Furthermore, the
ammonia will mix with water to produce ammonium hydroxide under alkaline
conditions, and will produce bicarbonate and carbonate ions. Alkalinisation of
urine by urease reaction had produced NH4, which will form carbonate ions and
trivalent ion phosphate. This is what will form struvite stones 6
ions for infection stone formation:

Figure 2.2. Schematic formation of struvite stones

Source: Source: Campbell-Walsh Urology 10th Edition. Urinary lithiasis.

Pearle, M. 45; 1283

3. Uric Acid Stones
Uric acid stones are common type of stone found in man and has the
incidence of 5% of the whole incident of stone. Patient with gout, a proliferative
disease, rapid weight loss and a history of the use of cytotoxic drugs have a high
incidence in uric acid stones. Not all patients with uric acid stone experience
hyperuricaemia. Increased levels of uric acid in the urine is triggered by lack of
fluid and excessive consumption of purine. There are 3 main factors in the
formation of uric acid stones is pH low urine, low urine volume
and hyperuricosuria. Factor The main pathogenesis is low urine pH for most
patients with stones uric acid levels were normal excretion of uric acid.7

Figure 2.3. Scheme of uric acid stone formation

Source: Campbell-Walsh Urology 10th Edition. Urinary lithiasis. Pearle,
M. 45; 1277
Hyperuricosuria be a predisposing factor in stone formation uric acid and
calcium oxalate stones for causing supersaturation of urine. Patients with urinary
uric acid levels below 600 mg / day have stone less than patients with low levels
of uric acid above 1000 mg / day in the urine. Uric acid stones may be
generated congenital, acquired, or idiopathic. Congenital abnormalities associated

10

with uric acid stones involving the renal tubular transport of uric or uric acid
metabolism cause hyperuricosuria. Acquired disorders may include chronic
diarrhea, the decline in the volume of urine, diseases myeloproliferative, height
consumption of animal protein, and drugs that cause three factors Issuer 5.
2.3.

Clinical Manifestations and Evaluation of Urinary Stone Patients

Many of the symptoms and signs that can accompany stone disease

urinary tract. However, there are also some stones that are not show symptoms or
signs of special but found in results radiological examinations. The symptoms
often occur in patients can of pain, hematuria, nausea, vomiting, fever and bowel
disorders small such as frequency, urgency and dysuria. 8
Pain is a symptom that most often accompanies stone disease urinary tract,
ranging from pain of moderate to severe pain requiring analgesics. The pain
usually occurs in the urinary tract stones top, with the character of the pain
depends on the location of stone, stone size, degree of obstruction, and the
anatomical conditions of each person is different. The pain can be
either colic or non-colic 5
Colicky pain in the kidney usually occur due to stretched ureter
or collecting duct, caused by urinary tract obstruction. Obstruction also causes
increased intraluminal pressure, stretched nerve endings, and local mechanisms at
the site of obstruction such as inflammation, oedema, and irritation of the mucous
Hyperperistaltic effect on pain experienced by the patient 1
Obstruction in renal calyx, pain that occurs in the form of pain which in
the flank or back area with varying intensity. Pain can arise at excessive fluid
consumption. Obstruction renal pelvic stones with a diameter of above 1 cm, the
pain will appear on costovertebra corner. Pain can arise in the form of pain that
dim until a sharp pain that is constant and unbearable, and can spread to
the flank and abdominal quadrant area ipsilateral 1.
Obstruction in the proximal ureter causes pain on the angle costovertebra
intense and can propagate along the dermatomes of spinal nerves are affected. In
the upper ureteral obstruction, pain spread to the lumbar region, while the

11

obstruction midureter pain spread to the lower abdomen area. Obstruction in the
distal part of the ureter likely to cause pain spread to the groin and testes in men
or labia majora in women. The pain conducted through the ilioinguinal nerve or
genital branch of the nerve genitofemoral 1.
The incidence of hematuria in patients with urinary tract stones is
estimated 90% based on theory. However, the absence hematuria is not a
guarantee that urinary stones do not occur. An estimated 10% of patients had
negative results on the examination microscopy and dipstick 9
Complete urinalysis is required to ensure diagnosis of urinary tract stones
by hematuria and crystalluria and pH urine. Patients usually complain of urine
colour like dark tea. On 10-15% of cases, microhematuria not happen due to a
complete obstruction of ureter. Fever associated with urinary tract stones shows a
condition emergency. Fever is one of the symptoms of sepsis in addition to
tachycardia, hypotension and vasodilation. While the nausea and vomiting caused
by colic is felt by the patient 1.
After digging patient history, evaluation is physical examination. Detailed
physical examination is a component important in the evaluation of patients with
urinary tract stones. Things that can be seen as tachycardia, sweating, nausea,
fever, and rule out the possibility of abnormalities in the abdomen and Lumbar 8
Examination of the next suggestion is radiology. When available,
ultrasonography is a diagnostic instrument main radiological patient. Ultrasound
can identify stone location in the calyx, pelvis, ureter, and others. In the United
States, in patients with urinary tract stones, ultrasound examination has sensitivity
78% and specificity of 31% 7.
In addition to ultrasound, radiological examination otherwise be done is
plain radiography examination. Plain film (KUB) may use to look at the position
of stones in the kidney, ureter, and bladder. KUB has 90% sensitivity in the
detection of urinary tract stones, and 92% of stone can be determined through this
action 7.

12

KUB can be used with the option of inspection that is fast, economical and
accurate. However, plain radiography cannot be used to detect stones
non- opaque and stone size below 2 mm8
IVP (intravenous pyelogram) is a diagnostic procedure for determine
intrarenal stones and ureteral anatomical condition. IVP has specivity high
sensitivity and to determine the location of the stone and degree of
obstruction. IVP can detect radiolucent stones and disorders anatomy associated
with stone formation. 8
Non-Contrast computed tomography (NCCT) has become the standard in
diagnosing acute pain replace intravenous urography (IVU) which has become the
gold standard for many years. NCCT also can used for diagnosis of peritoneal and
retroperitoneal disorders and help when the diagnosis is uncertain. NCCT can
detect

acid

rock

urate

and xanthine stone

that

is radiolucent on

plain

radiography. NCCT has a sensitivity of 97% and specificity 96% 7.

2.4.

Management of Urinary Tract Stone

1. Conservative Management
Conservative management is given to patients without a history urinary

tract stones. Non-pharmacological Management can reduce recurrent incidents of

stone per 5 years up to 60%. conservative management form:
1. Consumption of at least 8-10 glasses of fluid per day with a purpose keep
the volume of urine that amounted to more than 2 litres per day
2. Reduce animal protein consumption of around 0.8 to 1.0 g / kg / day to
reduce the incidence of stone formation
3. A diet low in sodium approximately 2-3 g / day or 80-100 mEq / day
effective to reduce calcium excretion in patients with hypercalciuria
4. Prevent the use of drugs that can cause stone formation as calcitrol,
calcium supplements, diuretics Strong and probenecid
5. Reduce foods high oxalate levels for reduce the formation of stones. The
food should be reduced such as tea, spinach, chocolate, nuts and others 5

13

Figure 2.4 Algorithm non-invasive treatment of urinary tract stones

Source: Campbell-Walsh Urology 10th Edition. Evaluation and Medical
Management of Urinary lithiasis. Pearle, M. 46; 1331
2. Specific Management
1. Stone calcium
For Absorptive hypercalciuria type I may be given diuretics thiazides 2550 mg for lower levels of calcium in the urine up to 150 mg / day. This occurs
through the falling volume of urine resulting compensate for the increased
reabsorption of sodium and calcium in the tubules proximally. Another alternative
that can be given is chlorthalidone 25-50 mg, indapamide 1.25 to 2.5 mg / day 1.
In type II AH, do dietary restriction of calcium 600 mg / day. Restriction
of dietary sodium is also important to reduce hypercalciuria. Thiazides and
potassium citrate supplements can also be given if management conservative
ineffective. In type III AH, given that orthophosphate will reduce levels of 1,25
(OH) 2D3 and increase levels of inhibitor in the urine.
Thiazides is also given to renal hypercalciuria to improve tubular
reabsorption of calcium. This will normalize calcium levels and decreases in

14

serum parathyroid hormone levels. Sodium diet also reduced to 2 g / day and
maintain urinary sodium below 100 mEq / day.
In primary hiperoksalouria, pyridoxine may decrease production
endogenous oxalate. The recommended dose of pyridoxine is 100-800 mg / day.
Oral Orthophospate also be given in doses four times a day. Oral magnesium,
potassium citrate supplements and consumption of fluids plus helping to treat 7
Patients with hypocitraturia given potassium citrate for increase
intracellular pH and citrate production. In addition to potassium citrate, daily
consumption of lemon juice dissolved in 2 litres of water will increases levels of
citrate in the urine 1.
2. Uric acid stones
For patients with uric acid stones, treatment should be done is conservative
management assisted by administration drugs. Giving acetazolamide 250-500 mg
at night will useful to control the pH of urine. Allopurinol given if levels uric acid
in the blood above 800 mg / day and urinary pH above 6.5. Potassium citrate
supplementation is useful for maintaining the pH of the urine remains alkali is
about 6.5. PH levels in urine should be maintained in order not to go up up above
7, to reduce the risk of the formation of calcium phosphate stones 5.
3. Stone cystine
Patients with cystine stones should increase fluid intake in order get about
3.5 liters of urine every day for maximum dissolution of cysteine
stones. Alkalinization of urine using potassium citrate or sodium bicarbonate is
used to maintain the urine pH 7.5-8.5. Alkaline urine will increase the solubility
of cystine in the urine 10.
If the above treatment is not successful and levels of cystine in the urine
above 3 mmol per day, it can be given tiopronin. dose tiopronin used is 250 mg
per day. Tiopronin considered better than predecessor the D-penicillamine are
considered to pose a lot side effects 10.

15

3. Modality Therapy
1. Percutaneous Nephrolithotomy (PCNL)
PCNL technique is done through access to lower calyx, hereinafter
dilatation using a balloon dilator or Amplatz dilators with help fluoroscopy and
crushed stones using electrohydraulic, ultrasonic or laser lithotripsy 5
Indications do PCNL is staghorn stones, kidney stones sizes above 3 cm,
cystine stones, kidney abnormalities and channels upper urinary, failure in ESWL
and uretroscpy, and rock on kidney transplantation outcome. PCNL cannot be
carried out under conditions bleeding, urinary tract infections are not controlled,
and the factors which resulted PCNL is not optimal as obesity and splenomegaly 1
2. Uretroscopy (URS)
URS is the gold standard for the treatment of ureteral stones middle and
distal. The use uretroskop with a small caliber and balloon dilatation stone-free
rate increases dramatically. There variations in lithotries that can be placed
on uretroscope included electrohydraulic, ultrasonic probes, laser and pneumatic
systems such as Switzerland lithoclast. Lithotrites electrohydraulic have 120-volt
power produces a shock wave. Lithotrites ultrasonic own resources piezoceramic
energy that can convert electrical energy into a wave ultrasonic 25,000 Hz, so it
can lead to fragmentation effective the stones 1
URS effectively used in ureteral stones with a success rate 98-99% at the
distal ureteral stones, 51-97% in mid ureter stones and 58-88% the upper ureteral
stones. URS has complications such as mucosal abrasion, ureteral perforation, and
stricture ureter 1.
3. Extracorporeal Shock Wave Lithotripsy (ESWL)
The working principle of ESWL tool is using shock waves. The shock
waves are pressure waves that high energy can be streamed over the air or
water. When walking past the two a different medium, the energy is released,
causing the stone fragmented. The shock wave caused no damage when passing a
substance with the same density. Therefore, water and body tissue has the same
density, the shock wave does not damage the skin and tissues in the body. Urinary
tract stones have different acoustic densities, and when subjected to shock waves,

16

rocks will be broken, fragmented Once the stone, the stone will come out of
urinary tract 8.
ESWL action can only be performed on a stone with the location kidney
and ureter. More than 90% stone in adults can treated by ESWL. ESWL therapy is
the main option on proximal ureteral stones with size below 10 mm and 10-20
mm, either the proximal and distal ureter. The success rate of ESWL action to
stone with a size less than 20 mm is 80-90%. Stones located in the lower
calyx and ureter has a degree of fragmentation of 60-70%. However, the success
rate is also determined by the composition of the rocks and the implementation of
the ESWL 1.

17

CHAPTER 3
PATIENT STATUS
3.1.

Identity
Name

: Nuardin Simatupang

Age

: 50 years-old

Sex

: Male

Occupation

: Fisherman

Address

Admission Date

: 15th December 2016

Lk.II Lubuk Tuka Pandan, Tapanuli

Tengah

3.2.

Anamnesis
Chief Complain

: Flank Pain

History of Present Illness

The patient has been suffering from the pain for 3 months before he got
admitted to the hospital. The pain was localized on the left flank, but sometimes
migrating to the umbilical region. No history of passing stone, haematuria (+),
nausea, vomiting and sweating was found. There was no fever and cloudy urine.
Patient also claims that there is pain on his supra pubic region and dysuria at the
end of micturition. Incomplete emptying (+), frequency (+).

3.3.

Post Medical History

: Hypertension (-) DM (-) Hyperuricemia (-)

Previous Medication

: Unclear

Present Status

Consciousness

: Compos Mentis

Blood Pressure

: 120/70 mmHg

Pulse

: 84 times / minute

Respiratory Rate

: 20 times / minute

Temperature

: 36.9oC

General Status

: Malaise

18

Nutritional Status
3.4.

: Good

Physical Examination
General Survey

Head
o Eyes
o Ears
o Nose
o Mouth
Neck
Thorax
o Inspection
o Palpation
o Percussion
o Auscultation
Abdomen
o Inspection
o Palpation
o Percussion
o Auscultation

:
:
:
:
:

Inferior Conjunctiva Palpebrae: Anaemia (-/-)

Normal
Normal
Normal
Lymph Node Enlargement (-/-)

:
:
:
:

Symmetrical Thorax
Stem Fremitus Right = Left
Sonor
Vesiculer on both sides

:
:
:
:

Symmetrical Abdomen
Soepel
Tympani
Normoperistaltic

Urologic Status

Flank Area
o Inspection
:
o Palpation
:
Supra Symphysis Area
o Inspection
:
o Palpation
:
Genital
:
Digital Rectal Exam :

Normal
Pain (+)
Normal
Pain (-)
Male, OUE Normal
Tight Sphincter Ani, Smooth Mucous, Bulging

Prostate (-), Glove: Clean

3.5.

Support Examination
1. Laboratory Examination

Type Examination

Result

Normal

HAEMOTHOLOGY

19

Hemoglobin (HGB)

14,7

1318

Red Blood Cells

5.39

4,50-6,50

White Blood Cells

11.770

411x103

Hematocrit

44

3954%

Platelet

353.000

150450x103

RENAL FUNCTION TEST

Urea

45

18-55 mg/dL

Creatinine

3.95

0,71,3 mg/dL

Natrium (Na)

136

135155 mEq/L

Potassium (K)

4,7

3,65,5 mEq/L

Chloride (Cl)

106

96106 mEq/L

pH

7,300

7.35 7.45

pCO2

28,0

38 42 mmHg

pO2

186,0

85 100 mmHg

Bicarbonate

13,8

22 26 mmol/L

Base Excess

-11,2

(-2) (2) mmol/L

ELECTROLITE

BLOOD GAS ANALYSIS

2. Chest X Ray
Conclusion
:
There is no heart and lung abnormalities
3. Ultrasonography

20

Left Kidney
: Acoustic Shadow (-), Hydronephrosis (+)
Right Kidney
: Acoustic Shadow (-), Hydronephrosis (-)
Urinary Vesika
: Acoustic Shadow (+), Mass (-)
Conclusion
:
Bladder Stone + Moderate Hydronephrosis (L)

4. CT Scan

21

Conclusion

Left Nephrolithiasis + Left Hydronephrosis due to ureter stone at proximal

+ Vesicolithiasis
3.6.

Diagnose

Proximal Ureter Stone (L) + Moderate Inferior Calyx Hydronephrosis (L)

due to ureter stone + Bladder Stone
3.7.

Management
1.
2.
3.
4.

IVFD NaCl 0.9% 20 gtt/i

Injection Ketorolac 30 mg/8 jam
Injection Ranitidine 50 mg/12 jam
Planning Open Ureterolithotomi (L)
CHAPTER 4
DISCUSSION

THEORY
CASE
Many of the symptoms and signs that From the patient we found:
can accompany stone disease urinary

Flank and supra pubic

pain
Hematuria
Nausea
Vomiting
Dysuria

tract. However, there are also some

stones that are not show symptoms or
signs of special but found in results
radiological examinations.
The symptoms often occur in patients
can

of

pain, hematuria, nausea,

vomiting, fever and bowel disorders

22

small such as frequency, urgency and

dysuria
In addition to ultrasound, radiological Ultrasonography
examination otherwise be done is Left Kidney

: Acoustic Shadow (-),

plain radiography examination. Plain Hydronephrosis (+)

film (KUB) may use to look at the Right Kidney : Acoustic Shadow (-),
position of stones in the kidney, ureter, Hydronephrosis (-)
and bladder. KUB has 90% sensitivity Urinary Vesika: Acoustic Shadow (+),
in the detection of urinary tract stones, Mass (-)
and 92% of stone can be determined Conclusion
through this action.
Non-Contrast

Bladder
computed

:
Stone

Moderate

Hydronephrosis (L)

tomography (NCCT) has become the

standard in diagnosing acute pain CT Scan
replace intravenous urography (IVU) Conclusion
which has become the gold standard Left

Nephrolithiasis

Left

for many years. NCCT also can used Hydronephrosis due to ureter stone at
for

diagnosis

of

peritoneal

and proximal + Vesicolithiasis

retroperitoneal disorders and help

when the diagnosis is uncertain.

23

CHAPTER 5
CONCLUSION

5.1. Conclusion
Mr. NS, male, 50 years old, came to Emergency Unit
General Reference Centre Hospital Haji Adam Malik Medan with
chief complain pain in left plank and diagnosed by

Proximal

Ureter Stone (L) + Moderate Inferior Calyx Hydronephrosis (L) due to ureter
stone + Bladder Stone. Then, he was planned to do open uterolithotomi.

24

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25