Ureterolithiasis 1/3 Proximal Dextra + Hydroureter Proximal Dextra + Grade II Hydronephrosis Dextra

Presented By: Tia Monita 04114708009

Consultant:
Dr. Marta Hendry, Sp.U

Patient Identification
Name : Mr. J Age : 26 years old Sex : Male Address : Sako, Palembang Nationality : Indonesian Religion : Moslem Occupation : Labourer Admitted : 30th of August 2012

ANAMNESIS

Autoanamnesis taken on 31st of August 2012

Chief complaint: pain on the right waist

pain on the right waist Sharp and intermittent Came to GP got medicines pain relief

Intermittent pain on right waist Reddish urine Pain on urinating (-), frequency (), urgency () Patient drank a lot of water

pain on the right waist Sharp and intermittent More frequent Referred to his abdomen, around the navel Fever (-), nausea(-), vomiting(-)

22 years before admission

26 months before admission

21 month before admission

 Patient usually has low intake of water. His frequency of urinate was 3-4 times per day, urine was yellow, no pain on urinating, no blood, no history of gritty urine. Defecation was normal.

History of past illness:

No history of urinary stone. No history of urinary tract infection. No history of gout. No history of jaundice.

Family history:
No history of urinary stones

Physical Examination
General Examination (31st of August 2012) Appearance Consciousness : good : compos mentis

Blood pressure
Pulse rate

: 120/70 mmHg
: 78 x/min

Respiratory rate
Temperature

: 22 x/min
: 36,6 0C
7

Eyes

: conjunctiva palpebra anemic (-/-),

sclera icteric (-/-), pupils isokor, light reflex (+/+) Neck Thorax : no abnormalities : no abnormalities

Abdomen : refer to local examination Genital : refer to local examination

Upper extrimities: no abnormalities

Lower extrimities: no abnormalities
8

Local Examination

CVA region

dextra Inspection : bulging (-) Palpation : pain (+) Ballottement (-)

sinistra (-) (-) (-)

Suprapubic region Inspection : bulging (-) Palpation : pain (-)

External genitalia region

Inspection : no abnormalities, bloody discharge (-)

Rectal toucher
TSA good, ampulla not collapse, smooth mucosa, no enlargement of prostate, feces (+), blood (-).

Supportive Examination
Laboratorium findings (6/8/12) Routine blood:

Hemoglobin : 14,2 gr/dL Hematocryte : 41 vol% ESR : 51 mm/hr Leucocyte : 8800/mm3 Thrombocyte : 315.000/mm3 Bleeding time : 2 minutes Clotting time : 8 minutes

Clinical Chemistry:
BSS Ureum Creatinine Na+ K+ : 75 mg/dL : 22 mg/dL : 1,0 mg/dL : 145 mmol/l : 4,2 mmol/l

Urine analysis:
Epitel cell Leucocyte Erytrocyte : (-) : 2 / hpf : 1 / hpf

Urine culture:
No bactery

BNO

Result : Radio-opaque shadow at the level L3-4 dextra (size: 1,3 x 0,8 cm)

IVP

IVP (5 minutes)

IVP (15 minutes)

IVP (30 minutes)

IVP (post-micturition)

 Interpretation:

Grade II Hydronephrosis dextra Hydroureter proximal dextra e.c. ureterolithiasis 1/3 proximal

Working Diagnosis
Ureterolithiasis 1/3 Proximal Dextra + Hydroureter Proximal Dextra + Grade II Hydronephrosis Dextra

Treatment

Ureterolithotomy

PROGNOSIS
Quo ad vitam : bonam Quo ad functionam : bonam

Thank you

Questions?
Vico : how bout the prognosis? Will it be recurrence? 2. Arif : why you ask history of jaundice and what is the relationship ? 3. Nabila : 1. why creatinin clearance in normal range? 2. compensation of other kidney? 3. treatment of this pt? 5. Alif : risk factor from this pt that can cause this disease?
1.

Assil : other examination beside BNO? 7. Ayna : is there any correlation with hydronephrosis with ureterolithiasis? 8. Etha : any other medication and interpretation of urine analysis ? 9. Tinton : how to make a diagnosis? Step by step 10. Ila : why you ask history of gout? 11. Eta : how to prevent ureterolithiasis?
6.

12. Interpretation ivp and how to diagnosis hydronephrosis? 13. Mita :GP compentence? 14. anies: ballotement (-) ? 15, dr martha : when is the suitable medical theraphy given?