Presented By: Tia Monita

04114708009

Consultant:Dr. Marta Hendry, Sp.U

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

II Hydronephrosis Dextra

Patient Identification

Name : Mr. JAge : 26 years oldSex : MaleAddress : Sako, PalembangNationality : IndonesianReligion : Moslem Occupation: LabourerAdmitted : 30th of August 2012

 

ANAMNESIS

 Autoanamnesis taken on 31st of August 2012

Chief complaint: pain on the right waist

pain on the right waistSharp and intermittentCame to GP → got medicines → pain relief

Intermittent pain on right waistReddish urinePain on urinating (-), frequency (-), urgency (-)Patient drank a lot of water

pain on the right waistSharp and intermittentMore frequentReferred to his abdomen, around the navelFever (-), 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

7

Physical Examination

General Examination (31st of August 2012)

Appearance : good

Consciousness : compos mentis

Blood pressure : 120/70 mmHg

Pulse rate : 78 x/min

Respiratory rate : 22 x/min

Temperature : 36,6 0C

8

Eyes : conjunctiva palpebra anemic (-/-),

sclera icteric (-/-), pupils isokor, light reflex (+/+)

Neck : no abnormalities

Thorax : no abnormalities

Abdomen : refer to local examination

Genital : refer to local examination

Upper extrimities: no abnormalities

Lower extrimities: no abnormalities

Local Examination

CVA regiondextra sinistra

Inspection : bulging (-) (-)

Palpation : pain (+) (-) Ballottement (-) (-)

Suprapubic regionInspection : 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 ExaminationLaboratorium 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 : 75 mg/dL◦Ureum : 22 mg/dL

◦Creatinine : 1,0 mg/dL

◦Na+ : 145 mmol/l◦K+ : 4,2 mmol/l

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

Urine culture:◦No bactery

BNO

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

IVPIVP (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 : bonamQuo ad functionam: bonam

Thank you

Questions?1. 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?

6. 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?

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?