DUTY REPORT 07/06/2017

ZDP/RHE/RAL/WDS
 Identity
• Name : Mrs. Yayuk Agustini
• Sex : Female
• Age : 47 y.o
• Address : Dongeng Jarak Kulon, Jombang
• Register : 12593835
• Insurance : BPJS
• Doctor : Zulfikar Dian Paradilan (ZDP)
 Anamnesis
Patient was consulted from digestive surgery department with
intraabdominal mass + Right Staghorn stone
Chief complaint : General Weaknes
• Patient with intraabdominal mass and general weaknes
• Mass in right abdomen felt since 2 months ago and getting
bigger, pain(+)
• Lost appetite since 2 weeks before admitted to hospital
• Nausea (+), Vomitting (-), Febris (+) since 1 week before
admitted
• History of stone expulsion (-), hematuria (-)
• History of DM & HT was denied
• History of surgical procedure (-)
 Physical examination
• General condition : weak Karnoffsky score : 60 %
Vital sign:
• BP : 121/73 HR: 98x/min RR: 16x/min t ax: 37,7 C
• General State :
• Head/Neck : A(+) I(-) C(-) D(-)
• Thorax : Cor normal Pulmo: wnl
• Abdomen : defans (-), bowel sound (+)N,
Mass in right abdomen
• Extremity : wnl
 Physical examination
Urological Examination :
• Flank region : mass (+/-) size 15x15cm, cystic,
pain(++) reddish (+)
• Flank pain : (+/-)
• suprapubic : Bladder seems empty, mass (-)
• Ext Genital : Female, OUE (+), inserted DK 16 fr, UP :
500cc/8hours, yellow clear
• RT : AST (+) N, smooth mucose, mass (-)
• VT : v/v dbn, fluor (-) fluxus (-)
Physical Examination
Physical Examination
 Additional Examination

laboratory 07/06/17 Urinalysis

Hb (g/dl) 7,3 pH 7,0
Leu (/UL) 10,71 Eri > 100 /lp
Trombosit (/UL) 591 Leu > 100 /lp
BUN (mg/dl) 15
SK (mg/dl) 0,7
Blood Gas Analysis
SGOT 14
pH 7,517
SGPT 6
pCO2 25,3mmHg
PTT (s) 12
pO2 193,5 mmHg
APTT (s) 35,7
HCO3 20,7 mmol/l
Na/K/Cl (mmol/l) 125/4,5/87
BE -2,4 mmol/l
Alb (g/dl) 2,71
SaO2 99,7 %
RBG(mg/dl) 201
CRP 153,66
Chest x-ray (07/06/17)

Cor and pulmo within normal limit

KUB (07/06/17)
• Staghorn radioopaque
shadow at Right VL 2-4
• Ground Glass appearance
at right abdomen
 CT Scan Abdomen with contrass
(07/06/17)

- Multiple abcess at right psoas mayor m., right iliacus m., right quadratus lumborum m.,
right iliocostalis m.., right tranversus abdominis., right internus et externus obliqus
abdominis m., expand to right retroperitoneal until subhepatic area push right kidney
and pancreas to anterior, push bowel, inferior cava v., A/V mesenterica superior to left
- Right Staghorn stone + Right Hydronefrosis grd IV
- Hepatosplenomegaly
- Multiple hipodense lession 18-27 HU
 CT Scan Abdomen with contrass
(07/06/17)

- Multiple abcess at right psoas mayor m., right iliacus m., right quadratus lumborum m.,
right iliocostalis m.., right tranversus abdominis., right internus et externus obliqus
abdominis m., expand to right retroperitoneal until subhepatic area push right kidney
and pancreas to anterior, push bowel, inferior cava v., A/V mesenterica superior to left
- Right Staghorn stone + Right Hydronefrosis grd IV
- Hepatosplenomegaly
- Multiple hipodense lession 18-27 HU
 Interdepartement consultation
– IPD : Right Peri-para renal abscess + Right
staghorn stone + Reactive Hiperglikemi + Anemia
hypochromic micrositer + Hiponatremia + Hipoalbumin
• HCHP Diet 2100 kcal/day
• Inf. NaCl 0,9% 800 ml in 10 H, followed Inf. NaCl 0,9% 21
dpm
• PRC Tranfusion 2 bag/day until Hb≥10
• Inf. Albumin 20% 100 ml in 4 H

– Cardio : CRI Class I

 Asessment
• Working Dx : Right peri-pararenal abscess
• Primary Dx : Right peri-pararenal abscess
• Secondary Dx : Right Staghorn Stone,
Decubitus ulcer grd IIB
• Compli Dx : Right Severe Hidronefrosis,
Anemia, Hiponatremia, Hipochloremia,
Hipoalbumin
 Planning
• Dx: urine culture + SST, Pus culture
• Tx:
• HCHP Diet 2100 kcal/day
• Correction of Hiponatremi
• PRC Tranfusion 2 bag/day until Hb≥10
• Inj. Ceftriaxon 2x1 gram
• Inj. Metronidazole 3x500mg

MR Discussion with Dr.dr.WDS, Sp.U(K):

Incision and drainage abcess
THANK YOU
 Operation (08/06/17)
• Incision drainage abscess – dr.zdp
– Incision subcostal 12, at cystic region
– Pus 1500 cc green yellow  pus culture
– Tunneling at anterior, superior and inferior
– Wash abses wound with warm normal saline
– Drain rectal tube
Pus Culture
Clinical Picture
post op
 Conditions this morning
• General condition : weak laboratory 08/06/17
Hb (g/dl) 10
• GCS 456
Leu (/UL) 7,79
• Vital sign: Trombosit 345
– BP : 112/78 PR:76 x/min RR: (/UL)
14x/min t ax: 36.7 C BUN (mg/dl) 12
– Drain rod 310cc/8 hours, serous SK (mg/dl) 0,58
hemoragic
Alb (g/dl) 2.12
– Urine prod 700cc/8 hours, yellow
clear RBG (mg/dl) 142
THANK YOU