CASE REPORT I.

Patient Identity Name Sex Age Adress Religion Race Occupation Relationship status Date of hospital admission Date of examination 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. : Mr. P : Male : 43 years old : Praya : Moeslem : Sasak : Farmer : Married : April 19th 2013 : April 20th 2013

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 A. Vital Sign Blood pressure Heart rate Respiration rate Temperature : 110/70 mmHg : 80 bpm : 20 tpm : 36,4oC : Moderate Consciousness/GCS : compos mentis/E4V5M6

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 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
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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. 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 Rbc Hct : 11,9 g/dl : 4,67.106 /ul : 37,5 %

MCV : 80,2 fl MCH : 25,5 pg MCHC: 31,7 g/dl Wbc Plt GDS : 15,8.103/ul : 394.103/ul : 115 mg/dl

Creatinin : 0,8 mg/dl Ureum : 25 mg/dl SGOT : 18 mg/dl SGPT : 8 mg/dl

BNO-IVP result

Conclusion : Hydronephrosis Grade IV ec stone as high as ureteropelvic junction Right ureter non visualized

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