CASE REPORT

I. Patient Identity

Name : Mr. P

Sex : Male

Age : 43 years old

Adress : Praya

Religion : Moeslem

Race : Sasak

Occupation : Farmer

Relationship status : Married

Date of hospital admission : April 19th 2013

Date of examination : April 20th 2013

II. Anamnesis

The chief history : right flank pain

Present disease history :

Patient complained right flank pain since 2 years past and getting worsed since 4

month before hospitalized. The patient said that pain was sharp and start from the

right flank reffered to his upper abdomen. He felt pain periodically and disturb her

activities. The pain was not associated by position and activity. Color of urine is

yellow, clear, and frequency 4-5 times a day. History of fever (-), nausea (-), vomiting

(-). Micturition complaints: History of pain during micturition (-), blood urinate (-),

wake up at night to urinate (-), stone urinate (-). The appetite was good, weight loss

(-). Defecation was normal, once daily, concistency firm and brown.

Past disease history :

The history of stone urinate (-) and blood urinate (-). Hypertension (-), diabetes mellitus (-),

asthma (-), uric acid (-)

Family disease history :

No family member with the same complaint. Hypertension (-), diabetes mellitus (-), asthma

(-),uric acid (-)

Drug allergy : (-)

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History of treatment : (-)

History of occupation :

Patient was a farmer. He spend most of his time a day by working in the farm. He said that he

drank 3 liters of raw water a day. History of smoke (+), more than 2 packs ciggaretes

consumption a day more than 25 years. History of coffe consumption (+), 2 cups a day, more

than 14 years.

III. Physical Examination

General condition : Moderate

Consciousness/GCS : compos mentis/E4V5M6

A. Vital Sign

Blood pressure : 110/70 mmHg

Heart rate : 80 bpm

Respiration rate : 20 tpm

Temperature : 36,4oC

B. General Status

Head and neck

o Head : normochepali, deformity (-)

o Eyes : anemis (-/-), icteric (-/-), pupil isocore, refleks (+/+)

o Noise : deformity (-)

o Mouth : sianotic (-)

o Neck : enlargement lymph node (-)

Thorax-Cardiovaskular

o Inspection : mass (-), lesion (-), chest wall movement simetric, retraction (-)

o Palpation : chest wall movement simetric, tenderness (-), vocal fremitus (+)

normal, mass (-)

o Percussion: sonor in both lung, percussion pain (-)

o Auscultation :

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

Cor: S1S2 single, regular, murmur (-), gallop(-)

Abdomen

o Inspection : distention (-), mass (-)

o Auscultation : bowel sound (+), normal

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o Percussion : timpani in whole region

o Palpation : tenderness (-), H/L/R not palpable, defans muscular (-), mass (-),

ballotement (-)

Upper and Lower extremity:

Deformity (-), oedem (-).

C. Urogenitalia physical examination

Costo vertebrae angle (CVA) region:

o Inspection: color same as the surrounding skin, mass (-), inflammation (-), scar

(-), hematome (-), bulging (-/-)

o Palpation : tenderness (+/-), mass (-), ballottement (-)

o Percussion : pain (+/-)

Suprapubic region

o Inspection: color same as the surrounding skin, mass (-), inflamation (-), scar

(-), sistostomy (-)

o Palpation : bladder distention (-), mass (-), tenderness (-)

Genitalia externa:

o Scrotum : enlargement (-), mass (-)

o Penis : circumsicated, scar (-), urethral discharge (-)

IV. Summary

Patient complained right flank pain since 2 years past and getting worsed since 4 month

before hospitalized. The patient said that pain was sharp and start from the right flank

reffered to his upper abdomen. He felt pain periodically and disturb her activities. The pain

was not associated by position and activity. Color of urine is yellow, clear, and frequency 4-5

times a day. History of fever (-), nausea (-), vomiting (-). Micturition complaints: History of

pain during micturition (-), blood urinate (-), wake up at night to urinate (-), stone urinate (-).

The appetite was good, weight loss (-). Defecation was normal, once daily, concistency firm

and brown. Patient was a farmer. Patient has history of smoke (+), more than 2 packs

ciggaretes a day, more than 25 years. History of coffe consumption (+), 2 cups a day, more

than 14 years. In the physical examination was found tenderness (+/-) and pain on percussion

(+/-) on CVA region.

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V. Working diagnosis

Suspect right ureter stone

VI. Differential diagnosis

Suspect right kidney stone

VII. Propose Examination

Routine blood examination, RFT, LFT

BNO-IVP

USG Abdomen

VIII. Laboratory Examination

CBC : (April 21th 2013)

Hb : 11,9 g/dl

Rbc : 4,67.106 /ul

Hct : 37,5 %

MCV : 80,2 fl

MCH : 25,5 pg

MCHC: 31,7 g/dl

Wbc : 15,8.103/ul

Plt : 394.103/ul

GDS : 115 mg/dl

Creatinin : 0,8 mg/dl

Ureum : 25 mg/dl

SGOT : 18 mg/dl

SGPT : 8 mg/dl

BNO-IVP result

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Conclusion :

Hydronephrosis Grade IV ec stone as high as ureteropelvic junction

Right ureter non visualized

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Thorax Rontgent Result

Interpretation :

Cor and pulmo normal

VIII. Diagnosis

Right ureter stone with hidronephrosis grade IV

IX. Planning:

o Pro ureterolithotomy + Dj stant

X. Prognosis:

Quo ad vitam : bonam

Quo ad functionam : dubia ad bonam

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