Professional Documents
Culture Documents
BY:
Hanan Afifah
H1A 012 019
SUPERVISOR:
Dr. Akhada Maulana, Sp. U
CASE PRESENTATION
1. Patient Identity
Name
Sex
Age
Address
Religion
Race
Occupation
Reationship status
Date of hospital admission
Date of examination
: Mrs. J
: Female
: 40 years old
: Selong
: Islam
: Sasak
: Housewife
: Married
: April 2nd 2016
: April 7th 2016
2. Anamnesis
- Chief Complaint : Right flank pain
- Present disease history :
Patient referred from Namira hospital Selong with right flank pain
because of suspect right stones kidney. This pain was felt since 1 year ago
and get worse in the last 3 months. Patient felt an intermittent pain and it
came suddenly while patient takes activities. Patient felt the pain was
sharply and was not spread to stomach, pubic region, and groin. This pain
was not affected by position of the body.
The urine color is yellowish, clear, with frequency 3-5 times a day.
Micturition complaints like painful when urinate (-), unsatisfied sensation
after urinate (-), woken up at night because of feeling to urinate (-),
difficult to start urinating (-), bloody urine (-), stone urinate (-), sandy
urinate (-), faltered urination (-), heat urinate (-).
Defecation frequency 1 times a day, brown coloured, consistency
normal, bloody stool (-). History of fever (-), nausea (-), vomiting (-)
malaise (-), headache (-) and dizziness (+).
- Past disease history:
Patient said that she had hematuria around 1 years ago, the
hematuria happened only once, painless, and without any stone during
urinated. The history of hypertension (-), asthma (+), diabetes mellitus (-),
gastritis (+), urinary tract infection (-).
- Family disease history:
No family member with the same complaint. History of urinary
stones in the family (-), blood urinate (-), asthma (+), diabetes mellitus (-),
hypertension (-), gastritis (-).
- History drug Allergy: (-)
- History of treatment: - History of Habitually:
Alcoholic (-), active smoker (-) Soda-drinking habitual (-). Coffedrinking habitual (-).
3. Physical Examination
General condition
: Moderate
Consciousness/GCS : Compos mentis/E4V5M6
Vital Sign
- Heart rate
: 80 bpm
- Respiration rate
: 20 rpm
- Temperature
: 36,7C
- Blood pressure
: 110/70 mmHg
General status
Head and neck
- Head : normochepali, deformity (-)
- Eyes : anemic (-/-), icteric (-), pupil reflex (+/+) isocor
3mm/3mm.
Noise : discharge (-), rhinorea (-), deformity (-)
Mouth : cyanotic (-)
Neck : enlargement of lymphnode (-)
Thorax-Cardiovaskular
- Inspection
: mass (-), lesion (-), movement of chest wall
-
wheezing (-/-)
Cor
: S1 S2 single, regular, murmur (-), gallop (-).
Abdomen
- Inspection
: distention (-), mass (-), scar (-)
- Auscultation : bowel sound (+), normal
- Percussion
: tympanic (+), pain (-)
- Palpation
: Hepar and lien unpalpable, pain (-)
Upper and lower extremity:
- Warm : + +
+ +
- Edema : - - Urogenital physical examination
- Costo vertebrae angel (CVA) region:
Inspection
: color same as the surrounding skin, mass
(-).
Genitalia externa
:
Secret (-), mass (-), inflammation (-), pain (-).
4. Summary
-
frequency 3-5 times a day without micturition complaints. Patient said that
she had hematuria around 1 years ago, the hematuria happened only once,
painless, and without any stone during urinated
Physical examination of the results obtained
-
Plan Examination
Routine blood examination
Routine urine examination
Electrolyte examination
Abdominal ultrasonography
BNO Radiography
Abdominal CT-Scan
Laboratory Examination (April, 4th 2016)
DL
Parameter
Result
HB
HCT
WBC
PLT
13,2 g/dl
40,5%
8,78 . 10^3/Ul
340 . 10^3/Ul
CHEMICAL
Parameter
GDS
SGOT
SGPT
Ureum
Kreatinin
Asam Urat
Result
98 mg %
16 U/L
12 U/L
30 mg %
0,6 mg %
4,9 mg %
ELECTROLITE
Parameter
Result
Na
K
Cl
138 mmol/L
3,3 mmol/L
104 mmol/L
9. Abdominal CT-Scan
10. Interpretation
- Appear the multiple staghorn stone in the right kidney with a size 3.28
cm x 1,17 cm and 0,49 cm x 0.81 cm.
-
11. Conclusion
- Staghorn stone ren dextra with hydronephrosis dextra.
- Hypokalemia
12. Diagnose
Right renal staghorn stone with hydronephrosis and hypokalemia
13. Planning Therapy
14. Prognosis
-
10