Vera Oktapiani

Supervisor: dr. Marta Hendry, SpU

SURGERY DEPARTMENT
MEDICAL FACULTY OF SRIWIJAYA UNIVERSITY
2013
PYELUM STONE
RENAL DEXTRA


Patient identification
Anamnesis
Physical examination
Laboratorium findings
USG
BNO-IVP
Diagnosis
Treatment
Prognosis
Case analysis

Name : Mr. B
Age : 29 years old
Sex : Male
Address : Penukal
Nationality : Indonesian
Religion : Moslem
Occupation : farmer
Admitted : 12
th
June 2013
Medical Record : 728225
Chief Complaint:
Right flank pain 1 years before admitted to hospital

History of Present Illness:
Right flank pain, and the pain spreading to right buttock.
The pain is intermittent but tend to settle
No pain when urinating
Hesitancy at the beginning of urinary flow, decreased force and
caliber of stream, and sensation of incomplete bladder emptying
are denied
No blood in the urine, and the patient didnt know that he ever had
stone or sand in urine
Nausea, vomiting (-) and no abnormality in defecation
Fever (-)
History of Past Illness:
No history of trauma at the stomach and back bone area
No history of recurrent urinary tract infections
No history of surgery
No history of hypertension, diabetes mellitus
A little drink of water, and begin to drink lots of water after
he complaint about his pain

Family History:
History with same complaint as the patient in family denied


General Examination(On 6
th
July 2013)

Appearance : good
Consciousness : compos mentis
Blood pressure : 130/80 mmHg
Pulse rate : 70x/min
Respiratory rate : 20 x/min
Temperature : 36,6
0
C
Eyes : Conjunctiva palpebra anemic (-/-), sclera
icteric (-/-), pupils isokor, light reflex (+/+)
Neck : No abnormalities
Thorax : No abnormalities
Heart : No abnormalities
Abdomen : refer to local examination
Genital : refer to local examination
Upper extremities : no abnormalities
Lower extremities : no abnormalities
Local Examination

CVA Region Right Left
Inspection : bulging (-) (-)
Palpation : ballottement (-) (-)
Percussion : percussion pain (+) (-)

Suprapubic Region
Inspection : bulging (-)
Palpation : tenderness (-)

External Genital Region
Inspection : bloody discharge (-)

Rectal Toucher
TSA good, no enlargement of prostate, feaces (-), blood (-).

(21/6/13)
Routine blood
Hemoglobin : 12,2 gr/dL (N : 14-18g.dL)
Hematocryte : 36 vol% (N : 40-48vol%)
Leucocyte : 7.600/mm3 (N : 5000-10000/mm3)
Thrombocyte : 227.000/mm3 (N : 200.000-500.000/mm3)

Clinical Chemistry:
BSS : 81 mg/dL
Ureum : 25 mg/dL (N : 15-39mg/dL)
Creatinine : 0,86 mg/dL (N : 0,9-1,3mg/dL)
Na
+
: 136 mmol/l (N : 135-155)
K
+
: 4,5 mmol/l (N : 3,5-5,5)

Urine analysis (10/5/13):
Epitel cell : -/LPB
Leucocyte : 3-6/ LPB (N : 0-5 / LPB)
Erytrocite : 60-83/LPB (N: 0-1/LPB)
Silinder : -
Kristal : -
Bakteri : +
Muccus : -
Jamur : -

No enlargement
of prostate

Accoustic
shadow in renal
dextra
Radio
opaque
appearance
in right side
between L1-
L2, 1,8 cm in
size
Normal
excretion of
renal

Radioopaque
appearance in
renal pyelum
Pyelum stone renal
dextra
Pyelolithotomy
Quo ad vitam :
bonam

Quo ad functionam :
bonam

RIGHT FLANK PAIN
KIDNEY PROBLEMS
BACK AILMENTS
GASTROINTESTINAL
PROBLEMS
KIDNEY PROBLEMS
renal stone,
pyeloneprhitis,
polycystic kidney disorders,
abscesses,
renal infarction
tumor
GASTROINTESTINAL
PROBLEMS
MUSCLE SPASM
Biliary colic
Cholecystitis/ch
oledocolitiasis
Appendicitis
No history of trauma can exclude muscle
spasm

no abnormality in defecation, nausea and
vomit (-) can exclude gastrointestinal
problems
From physical examination, there is no abnormality in except pain on
percussion in the CVA region.

From laboratory, there is slightly decrease of haemoglobin, it because
irititation renal wall by stone and make hematuria.

The urynalisa prove the hematuria with the high level of eritrocyte.

BNO-IVP and USG finding this patient is said to be diagnosed as
pyelum stone.

The risk factor in this patient is drinking habits. Little drink of water can
higher the risk of kidney stone.

Treatment for this patient is pyelolithotomy.

Quo ad vitam prognosis is bonam and quo ad functionam prognosis is
bonam.