CASE REPORT

Colic Suspect Ureterolithiasis

By: Irwinia Oktarini S. 0 .0!.000"

Super#isor: $r. Akha$a %aulana& Sp.U

I' OR(ER TO U'(ER)O T*E C+I'ICA+ ORIE'TATIO' , C+ER-S*IP AT T*E SUR)ER. /U'CTIO'A+ %E(ICA+ STA// %E(ICA+ /ACU+T. O/ U'I0AR 'TB )E'ERA+ *OSPITA+ 102"

CASE REPORT I. Name Age Sex Religion Address Number of medical record %ate of &os'ital admission %ate of examination Patient I$entity : Mr. M : 35 years old : Male : Moslem : Lombok Utara : !"#$# : (anuary #"t& # )* : (anuary#!t& # )*

II.

Ana3nesis

%ain co3plaint : rig&t flank 'ain Present $isease history : +atient referred from ,LU general &os'ital -it& sus'ect ureterolit&iasis. +atient com'lained t&at &e get rig&t flank 'ain since # days before &e came to t&e &os'ital. +ain refers to inguinal and lo-er abdominal. .olic 'ain/ disuria. 0re1uency * times e2ery day/ cloudy urine 345/ bloody urine 365. 0e2er 345 since # days ago/ s&i2ering 365/ +atient also com'lained left flank 'ain since yesterday 3#7t& # )*5. Not %efecation yet since 3 days ago. 8e denied t&e &istory of bloody urine/ nausea/ 2omitting/ &eadac&e. Past $isease history : 9&e &istory of stone -&en urinate 345 # times at t&e # years ago/ si:e ; # x # mm 3like 'ulled rice5 . 9&e &istory of ast&ma 365/ trauma 365/ &y'ertension 365/ diabetes mellitus 365 /a3ily $isease history : No family member -it& t&e same com'laint. Ast&ma 365/&y'ertension 365/diabetes mellitus 365 (ru4 aller4y : 365 *istory o5 treat3ent : 365.

III.

Physical E6a3ination : Moderate

<eneral condition A. 7ital Si4n

.onsciousness=<.S : com'os mentis=>*?5M$ @lood 'reasure 8eart rate Res'iration rate 9em'erature Nutritional status : )* =! mm8g :7 b'm

: # r'm : 3$/5o. : Normal

@. )eneral Status o *ea$ an$ neck o 8ead : normoc&e'ali/ deformity 365 o >yes : anemic 36=65/ icteric 36=65/ 'u'il reflex 34=45isocor 3 mm = 3 mm/

o Noise : deformity 365 o Mout& : cyanotic 365 o Neck : enlargement of lym'&node365 o Thora68Car$io#ascular o Ans'ection : mass 365/lesion 365/ mo2ement of c&est -all simetric/ retraction 365 o +al'ation : mo2ement of c&est -all simetric/ tenderness 365/ 2ocal fremitus 345 normal/ mass 365 o +ercussion: sonor in bot& lung/ 'ercussion 'ain 365 o Auscultation : +ulmo : 2esicular in bot& lung 34=45/ r&onc&i 36=65/ -&ee:ing 36=65 .or:S)S# single/ regular/ murmur 365/ gallo'365 o A9$o3en o Ans'ection : distention 365/ mass 365 o Auscultation : bo-el sound 345/ normal o +ercussion : tim'ani in -&ole region

o +al'ation : mass 365/ 8=L=R un'al'able/ defans muscular 365/enlargement of lym'&node365/ 'ressure 'ain 365. o Upper an$ +ower e6tre3ity: %eformity 365/ edema 365. .. Uro4enitalia physical e6a3ination o .osto 2ertebrae angle 3.?A5 region: o Ans'ection: color same as t&e surrounding skin/ mass 365/ inflammation 365/ scar 365/ &ematome 365/ bulging 36=65 o +al'ation : tenderness 34=45/ mass 365/ ballottement 365 o +ercussion : 'ain 34=45

o Su'ra'ubic region o Ans'ection: color same as t&e surrounding skin/ mass 365/ inflammation 365. o +al'ation : bladder distention 365/ mass 365/ 'ain 345. o <enitalia externa: o Scrotum : enlargement 365/ mass 365 o +enis : circumsicated/ scar 365/ uret&ral disc&arge 365/ cateter inserted/ BU+ 5 cc at 5 &our. o Rectal examination : o 9onus s'incter ani normotonik/ em'ty am'ulla recti/ rectum mucose sli''ery/ 'rostat 'al'able smoot&/ sulcus mediana 'al'able s&allo-/ sulcus lateralis left and rig&t lobus 'al'able/ su'erior 'ole 'al'able/ nodul 365/ t&ere is faeces in finger/ yellocolour/ blood 365. I7. Su33ary

+atient reffered from ,LU general &os'ital -it& sus'ect ureteral stone. +atient com'lained t&at &e get rig&t flank 'ain since # days before &e came to t&e &os'ital. +ain refers to inguinal and lo-er abdominal. +ain like colic/ disuria. 0re1uency * times e2ery day/ cloudy urine 345/ fe2er 345/ +atient also com'lained left flank 'ain 345/ Not %efecation yet since 3 days ago.

<eneral condition : Moderate/ .onsciousness=<.S : com'os mentis=>*?5M$/ blood 'reasure )* =! mm8g/ 8eart rate 7 b'm/ Res'iration rate : # r'm/ 9em'erature: 3$/5o./ nutritional status normal. An t&e '&ysical examination/ .osto 2ertebrae angle 3.?A5 region: tenderness 34=45/ 'ain 34=45/ su'ra'ubic region 'ain 345/ genitalia externa: cateter inserted/ BU+ 5 cc at 5 &our.

7.

:orkin4 (ia4nosis .olic e.c Sus'ect Ureterolit&iasis

7I.

(i55erential (ia4nosis A'endicsitis Uretritis +ielonefritis

7II.

Planin4 E6a3ination

o .@./ @UN/ creatinin serum/ Urinalysis o Abdominal Ultrasonogra'&y o @NB o A?+ 7III. +a9oratory E6a3ination;<anuary& 22th 102"=
Para3eter *9 Creatinin Ureu3 S)OT S)PT :BC P+T Para3eter Protein Erytrocyte +eukocyte 1 ,02,102" )5/ /! )7 #$ #* ))/#3 # ) 1 ,02,102" 4# 4* 4#

I>.

US) result ;<anuary& 2"th 102"=

?olume @+8 7* cc 4 &idronefrosis grade A dextra sus'ec 2esikuloureter refluks/ urolit&iasis 365.

>.

Theraphy A?0% RL# d'm .eftriaxone inC )gr=)#& Antrain )a=7&

>I.

Plannin4 >SDL

>II.

Pro4nosis Euo ad 2itam : bonam

Euo ad fungtionam : dubia ad bonam