1 UROLOGY CASE REPORT

Bilateral Staghorn Stones

By: Lalu Dedy Rusman H1A 006 023

Supervisor: dr. Akhada Maulana, Sp. U

DALAM RANGKA MENGIKUTI KEPANITERAAN KLINIK MADYA BAGIAN/SMF BEDAH FAKULTAS KEDOKTERAN UNIVERSITAS MATARAM/RSUP NTB 2012

2 CASE REPORT I. PATIENTS IDENTITY Name Age Sex Occupation Religion/ethnic Address Admitted to hospital Date of examination II. ANAMNESIS Main complaint : Patient confessed pain in her right flank. History of present illness : Patient admitted from Urologys polyclinic confessed pain in her right flank since 2 months ago which she felt more frequent in a last week. The pain is a deep, dull ache start from the right flank and referred to entire her back. She felt pain periodically and didnt disturb her activities. The pain was not associated by position and activity. History of fever (-), nausea (-), vomiting (-). Pain on micturition (-), intermittency (-), bloody urinate (-), cloudy (-), history of stone urinate (-). Color of urine is yellow, clear. Frequency 4-5 times a day. Defecation was normal, once daily, concistency firm and brown. History of past illness: She confessed pain on her right flank began at 2 years ago, but rare frequent and she felt pain was mild. She never checked up her condition in medical center. There was no history of admission in hospital. History of DM (-), Hypertention (-), and Asthma (-). : Mrs.T : 47 yo : Female : Housewife : Islam/Sasak : Karang Tapen, Mataram : April 9th, 2012 : April 14th, 2012

3 History of occupation : She was a traditional weaver for 20 years. She made mat from pandanus plant. she worked in sit position with legs crossed, approximately 8 hours a day. She also a farmworkers. She also confess less fluid intake, 4-5 glass a day. History of family illnes : There was no history of her family complaint as she had complaint. History of allergy : There was no history of food or medicine allergic. III. PHYSICAL EXAMINATION General condition :

General status GCS BP Pulse RR T

: well : E4V5M6 : 130/80 mmHg : 84 x/minute : 20 x/minute : 36,4 C

Head - neck :

Head Eye 3mm/3mm Neck

: normochepaly, symmetric, deformity (-) : anemic (-/-), icteric (-/-), Reflex of pupil (+/+), diameter : enlarge lymph node (-), enlarge tyroid (-), JVP

Ear, nose, throat : no deformity Inspection : simmetric (+), retraction (-), mass (-) Palpation : movement of chest wall simmetric (+), pressure pain (-), mass (-), ictus cordis (+) ICS V Percussion : Pulmo : Cor : sonor (+) : dull (+)

Thorax :

4 Superior line : ICS 2 sinistra inferior line: ICS 4 sinistra Right line Left line

: linea parasternalis dextra : linea midclavikularis sinistra : vesikuler +/+, rhonki -/-, wheezing -/: S1-S2 single, reguler, mur-mur (-), gallop (-)

Auscultasion : pulmo cor

Abdomen

Inspection : distention (-), mass (-), venectation (-), scar (-) Auscultation : Bowel sound (+) normal, borborygmus (-), methalic sound (-) Palpation : supel, pressure pain (+) at left hipochondriac, defans muskuler (-), hepar/lien not palpable. Percussion : timpani (+)

Uro-genital

regio flank and CVA : bulging -/-, inflammation sign (-), pressure pain -/+, ballottement (-/+), consistency firm, glossy, reguler. CVA tenderness (+/+) regio supra pubic : distention of bladder (-), mass (-), pressure pain (-) regio genitalia externa : signs of inflammation (-) Inspection : fistle (-), hemmoroid (-), abscess (-). Warm acral +/+, oedeme -/-

Anal-perianal Extremities IV. RESUME A fifty seven years old female, confessed pain in her right flank since 2 months ago. She felt more frequent in a last week. The pain is a deep, dull ache start from the right flank and referred to entire hers back. She felt pain periodically and didnt disturb her activities. The pain was not associated by position and activity. Fever (-), nausea (-), vomitting (-), micturition was normal. Defecation was normal. She was a traditional weaver for 20 years. She made mat from pandanus plant. she worked in sit position with legs crossed, approximately 8 hours a day. She also a farmworkers. She also confess less fluid intake, 4-5

5 glass a day. In the physical examination was found pressure pain -/+, ballottement (-/+), consistency firm, glossy, reguler. CVA tenderness (+/+) V. DIAGNOSIS Suspect Bilateral Kidney Stones + Left Hidronephrosis VI. DIFFERENTIAL DIAGNOSIS

Left Pyonephritis Right Pyelonephritis Left Policystic Kidney Disease

VII. PROPOSE SUPPORTING EXAMINATION

CBC, Urinalysis, SC, Ureum, Uric acid, Blood Glucose KUB, IVU, CT scan abdomen

Laboratory findings CBC ( April 4th, 2012 ) WBC RBC Hb HCT PLT SC Ureum Urinalysis pH Nitrite Protein : 6,0 : (-) : +2 : 6.58 K/L : 5.05 M/L : 14.7 g/dL : 47.3 % : 311 K/L

Blood Glucose : 101 mg% : 0,7 : 30

Uric acid : 4,9 mg%

Glucose : (-)

6 Keton : (-)

Urobilinogen: (-) Bilirubin : (-) Blood : +5 Leukocyte : >20 /vf Erythrocyte : >20 /Vf Epitel Crystaluria Ca oxalat : (-) Uric acid : (-) Uric amorf : (-) Triple phosphat : (-) Phosphat amorf : (-) Radiologic findings Plain Staghorn stones bilateral IVP
1. In renal function examination, be visible bilateral staghorn stones. Renal stone in the

: 8-10 /vf

right kidney (9 cm x 4 cm), renal stone in the left kidney (11,5 cm x 5,5 cm).
2. Contrass excretion in right kidney visiualized at 30th minute post contrass injection and

in the left kidney not visualized until 2 hours post contrass injection. 3. 4. Pelvicocaliceal Extasis grade III in the right kidney Vesica Urinaria normal Conclusion : bilateral staghorn stones, HN dextra grade III. VIII. PLANNING THERAPY Pro nefrolitotomi

IX. PROGNOSIS Dubia ad bonam