Case Report

Ureterolithiasis 1/3 Proximal

Sinistra + Nephrolithiasis
Dextra + Hydronephrosis
Bilateral Grade IV
By:
Kiki Rizki Arinda 04054821517071
Supervisor:
dr. Marta Hendry, Sp.U
MEDICAL FACULTY SRIWIJAYA UNIVERSITY
SURGERY DEPARTMENT RSUP MOH. HOESIN PALEMBANG
2016

BACKGROUN
D

IDENTIFICATION

IDENTIFICATION

Name : Erni Suswanti

Age : 46 years old
Date of Birth : 6th May 1970
Address : Kamboja street, Bandar Jaya, Lahat
Sex : Female
Religion : Islam
Date of admission : 17th February 2016
Med. Rec. : 937945
4

ANAMNESIS

Chief Complain
right and left sided back pain
that getting worse since 1
weeks ago.

ANAMNESIS
Patient felt right and left sided back pain,
intermittent.
A stone like black pebble found while
urinating (+)
Feeling pain while urinating (-), Sensation
of incomplete bladder emptying (-),
Change of urine color (-), The urinary
stream normal
The defecation normal
No fever, nausea or vomitting

2 months
before admission

The right and left

sided back pain
getting worse,
intermittent
Bloody urine
Fever
1 weeks
before admission
6

 1 weeks
before admission

Patient came to
RSUD Lahat

Got reffered to
RS BARI
Palembang

Got reffered to
Emergency
Room RSMH
Palembang
7

HISTORY OF PAST AND CHRONIC ILLNESS

10 years
agosided
intermittent
back pain (+)
stones like black
pebble found while
(+)
Has urinating
been
diagnosed

ureterolithi

Refused
the
surgery

3 years ago
The pain reappeared

While
waiting the
surgery
Agreed the
schedule,
surgery
the pain
The patient disappeared
asking to go
8
home without
doing the surgery

HISTORY OF PAST AND CHRONIC ILLNESS

No history of Diabetes Melitus

No history of CVD
No history of same diseases in her family

PHYSICAL EXAMINATION
GENERAL STATE:
General condition :
Sensorium

: Compos mentis

Blood pressure
Pulse rate

: 120/70 mmHg

: 88 x/m

Respiratory rate : 18 x/m

Temperature

: 36.7 0C
10

PHYSICAL EXAMINATION
SPESIFIC STATUS:
Head

: Normal

Eye

: Normal

Neck

: Normal

Thorax

CorI : Ictus cordis not seen

P : Ictus cordis not palpable
P : Within normal limits
A : heart sound I-II normal, gallop (-), murmur (-)
Pulmo I : Static and dynamic symmetric
P : Stemfremitus left = right lung
P : Sonor
A : Vesicular (+) normal, rh (-/-), wh (-/-)
11

PHYSICAL EXAMINATION
Abdomen

: Normal

Extremities
Superior : Normal
Inferior
: Normal

Genitalia

: within normal
12

LOCAL EXAMINATION
Costovertebral Angle Region
Dextra
I : Bulging

Sinistra
(-)

P : knock pain (+)

(-)
(+)

Suprapubic Region
I : Bulging (-)
P : Tenderness (-)

13

LABORATORY FINDINGS
(17TH FEBRUARY 2016)

Hematology
Hb

: 11,8 g/dL

Leucocytes : 12,2 x103/mm3

Hematocrites

: 35%

Platelet: 375 x103/uL

Diff. count

: 0/2/71/17/10

Blood Chemistry Screen

Glucose

: 348 mg/dL

14

LABORATORY FINDINGS
(1ST MARCH 2016)

Urine Culture
Bacteria
: (-)
Leucocytes : 0-1/LFA
Epithel
: 0-1/LFA

15

RADIOLOGY
Impression BNO-IVP:
Radio opaque stones
in the calix mayor of
right kidney and 1/3
proximal of left ureter
Hydronephrosis grade
IV

16

DIAGNOSIS
Working diagnosis
Primary diagnosis

: Colic ureter
: Ureterolithiasis 1/3 proximal sinistra + Nephrolithiasis dextra

Secundary diagnosis

: (-)

Complication diagnosis

: Hydronephrosis bilateral grade IV

17

TREATMENT
Open Surgery (nephrolitothomy dextra + ureterolithotomy sinistra)

18

OVER
VIEW
19

ANATOMY

20

UROLITHIASIS

21

THAN
K YOU
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