Case Report

CKD grade V et causa Hidronefrosis grade IV et causa ureterolithiasis dextra

Yovita Devi Kornelin

IDENTITY
Name : Mrs. A Age : 62 years old Sex : female Address : Anjun Kanoman, Karawang Barat Occupation : housewife Religion : Islam Marital status : married

Date of admission Taken from

: 26th Nov 2012 : Jatisari

Anamnesis
Autoanamnesis and alloanamnesis on Monday, November 26, 2012 at 6.00 a.m.

CLINICAL HISTORY
MAIN COMPLAINT Pain on the right side of waist since 4 months

ADDITIONAL COMPLAINT
unable to sleep due to pain

HISTORY OF PRESENT ILLNESS

A patient came to RSUD Karawang ER with pain in the right side of the waist since 4 months before hospitalize. At first, the pain can be cured with medication, but one or two hours reappeared. But now, the pain doesnt improve with treatment. Patients complain of unable to sleep because of the pain.

Urinating smoothly, yellow color, transparent, blood (-), and pain (-). Defecation every two days. Patients feel a little dizzy and weak. Fever, nausea, and vomiting are denied.

History of Past Illness

Two years ago had the same pain. And in the seven months before admission, urinating out the stone as large as papaya seeds.

Hypertension -

Diabetes mellitus -

Surgery -

Allergies -

Asthma -

Magh +

FAMILY HISTORY
Same condition +
Patients father had same condition, urinating out the stone as large as papaya seeds.

Diabetes mellitus -

Hypertension -

Asthma -

PERSONAL & SOCIAL HISTORY

Regular exersice (-)

Smoking (-)

Alcohol consumption (-)

Drug & medication (-)

GENERAL CONDITION
General Appearance Conciousness BB TB BMI
Moderately ill Compos mentis 50 kg 165 cm 18,5 kg/cm2 normal

VITAL SIGN
Blood pressure: 130/80 mmHg

Temperature: 36,2 C

Vital sign

Respiratory rate: 20x/menit

Heart rate: 80 x/menit

PHYSICAL EXAMINATION Head Eyes

Ears Nose Lip Neck
normochephaly

Conjunctiva anemic -/- , sclera ikterik -/-

Normotia, tragus pain -/-, auricular pain -/-, serumen -/, sekret -/-, hiperemis -/-, membrane timpani intact +/+ Septum deviasi -, konka hyperemic -/-, secret -/-, nostril breath oral hygiene +, arkus faring hiperemis - , tonsil T1-T1 calm

lymph nodes and thyroid was not palpable

THORAX
INSPEKSI
Ictus cordis is invisible

PALPASI
Ictus cordis is palpable at 5th ICS LMCS

PERKUSI
The right border of the heart : ICS 3-4 LSD The left border of the heart : ICS 5 1cm medial LMCS The upper limit of the heart : ICS 3 LMCS

AUSKULTASI
Regular I - II heart sound, no murmur and gallop

THORAX
INSPEKSI
Symmetrical, intercostalis retraction (-)

PALPASI
Equal vocal fremitus

PERKUSI
Sonor in both lung

AUSKULTASI
Vesicular breath sound in both lung, Wh -/-, Rh -/-

ABDOMEN
INSPEKSI
flat abdomen, caput medusa (-), smiling umbilicus (-)

PALPASI
Tenderness (-) , Liver and spleen are impalpable, distension (-), undulation (-), pain present (+), CVA +/- , Ballotemen +/-

PERKUSI
Tympanic, Shifting dullness (-)

AUSKULTASI
Bowel sound (+) normal, arterial bruit (-), venous hum (-) Catheter inserted with 200cc/ 10 hours Normal (1cc/kgbb/jam)= 500cc

EXTREMITY

Laboratory Findings
Tests Results Normal

Hb Ht Trombocyte Leucocyte HBsAg

9,3 gr/dl 31 % 348.000 6400 -

12-17 g/dl 37-48 % 150.000-450.000 5000-10.000 -

GDS
Ureum Creatinin Uric Acid

136 mg/dl
236,3 mg/dl 11,05 mg/dl 13,4 mg/dl

80-140 mg/dl
10-45 mg/dL 0,4-1,5 mg/dL < 6,5 mg/ dl

Laboratory Findings
TESTS

RESULT
yellow transparent
7,0 -

NORMAL

COLOUR TURBIDITY
pH PROTEIN REDUKSI SEDIMEN EPHITEL LEUCOCYTE ERYTHROCYTE CRISTAL CILINDER BACTERY

+
1-2 0-1

Positif 0 5 / LPB 0 5 /LPB Negatif Negatif Negatif

Plain Abdominal

BNO-IVP
5 menit 15 menit

Impression : Hidronefrosis dextra grade 4 ec obstruction of opaq stone as high as L3-4

GFR CALCULATION
GFR CALCULATION (140 age) x weight x 0.85 72 x plasma creatinin (140 62) x 50 x 0,85 = 5 72 x 11,05 CKD Stage V (GFR <15 or dialysis)

RESUME
Physical Examination
Pain present in right lumbar CVA ++/+ Ballottement +/

Anamnesis
Pain on the right side of waist since 4 months Urine like tea color and little turbid Enable to sleep due to pain

Adjuvant test
Hb : 9,3 % Ht : 31 Ureum : 236,3 mg/dl Creatinin : 11,05 mg/dl Uric acid : 13,4 mg/dl

DIFFERENTIAL DIAGNOSIS

CKD et causa Hidronefrosis et causa ureterolithiasis dextra CKD et causa Hidronefrosis et causa nephrolithiasis dextra CKD et causa Hidronefrosis et causa stricture ureter dextra

WORKING DIAGNOSIS

CKD grade V et causa Hidronefrosis grade IV et causa ureterolithiasis dextra

SUGGESTED EXAMINATION

USG

TREATMENT

Suggest : surgery treatment

PROGNOSIS

Ad vitam
Dubia ad malam

Ad fungtionam
Dubia ad malam

Ad sanationam
Dubia ad malam